The New York State
Balancing Incentive Program Work Plan
Submitted by:
The New York State Department of Health
November 25, 2013
Contact person:
Mark Kissinger
Director of the Division of Long Term Care
New York Balancing Incentive Program Director
New York State Department of Health
Empire State Plaza
Corning Tower, 14th Floor
Albany, NY 12237
[email protected]
518-402-5673
1
TABLE TEMPLATE
*Please replace the number of months with an actual date.
GENERAL NWD/SEP STRUCTURE
1.
All individuals receive standardized information and experience the same eligibility determination and enrollment processes.
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work Plan
Task
submission)*
1.1. Develop standardized informational
6/15/2014
State Office for
In progress Informational materials
materials that NWD/SEPs provide to
the Aging
individuals
(SOFA)/Kitazawa
1.2. Train all participating agencies/staff on
8/15/2014
Department of
Not started Training agenda and
eligibility determination and enrollment
Health (DOH)
schedule
processes
/Kissinger/Arnold
2.
A single eligibility coordinator, “case management system,” or otherwise coordinated process guides the individual through the
entire functional and financial eligibility determination process. Functional and financial assessment data or results are accessible
to NWD/SEP staff so that eligibility determination and access to services can occur in a timely fashion. (The timing below corresponds
to a system with an automated Level I screen, an automated Level II assessment and an automated case management system. NWD/SEP systems
based on paper processes should require less time to put into place.)
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work Plan
Task
submission)*
2.1. Design system (initial overview)
8/30/2013 (submit with
SOFA/Pferr
Completed
Description of the
Work Plan)
system
2.2. Design system (final detailed design)
4/1/2014
SOFA/Pferr
In progress Detailed technical
DOH/Kissinger
specifications of system
2.3. Select vendor (if automated)
8/31/2014
SOFA/Pferr
Not started
Vendor name and
DOH/Kissinger
qualifications
2
Major Objective / Interim Tasks
2.4. Implement and test system
Suggested Due Date
(from time of Work Plan
submission)*
2/28/2015
2.5. System goes live
8/31/2015
2.6. System updates
Semiannual after
8/31/2015
Lead Person
Status of
Task
Deliverables
SOFA/Pferr
DOH/Kissinger
SOFA/Pferr
DOH/Kissinger
SOFA/Pferr
DOH/Kissinger
Not started
Description of pilot rollout
Memo indicating system
is fully operational
Description of successes
and challenges
Not started
Not started
NWD/SEP
State has a network of NWD/SEPs and an Operating Agency; the Medicaid Agency is the Oversight Agency.
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work Plan
Task
submission)*
3.1. Identify the Operating Agency
8/30/2013 (submit with
DOH/Kissinger Completed
Operating Agency Work Plan)
New York State
Department of Health
3.2. Identify the NWD/SEPs
8/30/2013 (submit with
DOH/Kissinger Completed, List of NWD/SEP
Work Plan)
SOFA/Pferr
ongoing
entities and locations
3.3. Develop and implement a Memorandum of 4/1/2014
DOH/Kissinger
Ongoing
Signed MOU
Understanding (MOU) across agencies
SOFA/Pferr
3.
3
NWD/SEPs have access points where individuals can inquire about community LTSS and receive comprehensive information,
eligibility determinations, community LTSS program options counseling, and enrollment assistance.
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work Plan
Task
submission)*
4.1. Identify service coverage of all NWD/SEPs
1/1/2015
SOFA/Pferr
In progress
Percentage of State
DOH/Kissinger
population covered by
NWD/SEPs
4.2. Ensure NWD/SEPs are accessible to older
5/31/2014
SOFA/Kitazawa Not started
Description of
adults and individuals with disabilities
NWD/SEP features that
promote accessibility
4.
WEBSITE
The NWD/SEP system includes an informative community LTSS website; Website lists 1-800 number for NWD/SEP system.
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work
Task
Plan submission)*
5.1. Identify or develop URL
8/30/2013
SOFA/Pferr
Completed
URL
5.
5.2. Develop and incorporate content
7/15/2014
SOFA/Pferr
In progress
5.3. Incorporate the Level I screen into the
website (recommended, not required)
11/1/2014
SOFA/Rosenbaum
Ongoing
Working URL with
content completed
Working URL of Level I
screen and instructions
for completion
4
1-800 NUMBER
Single 1-800 number where individuals can receive information about community LTSS options in the State, request additional
information, and schedule appointments at local NWD/SEPs for assessments.
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work
Task
Plan submission)*
6.1. Contract 1-800 number service
11/1/2014
SOFA/Pferr
In progress Phone number
6.
6.2. Train staff on answering phones, providing
information, and conducting the Level I
screen
11/1/2014
SOFA/Kitazawa
Not started
Training materials
ADVERTISING
State advertises the NWD/SEP system to help establish it as the “go to system” for community LTSS
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
(from time of Work
Task
Plan submission)*
7.1. Develop advertising plan
9/30/2014
DOH/Kissinger
Not started
SOFA/Pferr
7.2. Implement advertising plan
12/31/2014
DOH/Kissinger
Not started
SOFA/Cochran
7.
Deliverables
Advertising plan
Materials associated
with advertising plan
5
CSA/CDS
A CSA, which supports the purposes of determining eligibility, identifying support needs, and informing service planning, is
used across the State and across a given population. The assessment is completed in person, with the assistance of a qualified
professional. The CSA must capture the CDS (a Core Data Set of required domains and topics).
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work
Task
Plan submission)*
8.1. Develop questions for the Level I screen
4/1/2014
DOH/Ambros
In progress Level I screening
questions
8.2. Fill out CDS crosswalk (see Appendix H in
8/30/2013 (submit with DOH/Ambros
Completed
Completed
the Manual) to determine if your State’s
Work Plan)
crosswalk(s)
current assessments include required
domains and topics
8.3. Incorporate additional domains and topics if 3/31/2014
DOH/Ambros
In progress Final Level II
necessary (stakeholder involvement is highly
OPWDD/
assessment(s); notes
recommended)
Woodward
from meetings
OMH/Gratton
involving stakeholder
input
8.4. Train staff members at NWD/SEPs to
8/15/2014
DOH/Ambros
In progress Training materials
coordinate the CSA
OPWDD/
Woodward
OMH/Gratton
8.5. Identify qualified personnel to conduct the
2/28/2014
DOH/Ambros
In progress List of entities
CSA
OPWDD/
contracted to conduct
Woodward
the various
OMH/Gratton
components of the CSA
8.6. Regular updates
Semiannual after
DOH/Ambros
Not started Description of success
8/31/2014 (Semiannual OPWDD/
and challenges
after 12 months)
Woodward
OMH/Gratton
8.
6
CONFLICT-FREE CASE MANAGEMENT
States must establish conflict of interest standards for the Level I screen, the Level II assessment, and plan of care processes. An
individual’s plan of care must be created independently from the availability of funding to provide services.
Major Objective / Interim Tasks
Suggested Due Date
Lead Person
Status of
Deliverables
(from time of Work Plan
Task
submission)*
9.1. Describe current case management system, 8/30/2013 (submit with
DOH/Kissinger
Completed
Strengths and
including conflict-free policies and areas
Work Plan)
weaknesses of existing
of potential conflict
case management
system
9.2. Establish protocol for removing conflict of 7/1/2014
DOH/Kissinger
Not started
Protocol for conflict
interest
removal; if conflict
cannot be removed
entirely, explain why
and describe mitigation
strategies
9.
.
DATA COLLECTION AND REPORTING
10. States must report service, outcome, and quality measure data to CMS in an accurate and timely manner.
Major Objective / Interim Tasks
10.1. Identify data collection protocol for
service data
Suggested Due Date
(from time of Work Plan
submission)*
8/30/2013 (submit with
Work Plan)
Lead Person
Status of
Task
DOH/Ambros
Completed
Deliverables
Measures, data
collection instruments,
and data collection
protocol
7
Major Objective / Interim Tasks
10.2. Identify data collection protocol for
quality data
Suggested Due Date
(from time of Work Plan
submission)*
8/30/2013 (submit with
Work Plan)
Lead Person
Status of
Task
DOH/Ambros
Completed
Deliverables
Measures, data
collection instruments,
and data collection
protocol
10.3. Identify data collection protocol for
8/30/2013 (submit with
DOH/Ambros
Completed
Measures, data
Work Plan)
collection instruments,
outcome measures
and data collection
protocol
10.4. Report updates to data collection
2/28/2014 (Semiannual**)
DOH/Ambros
Not started
Document describing
protocol and instances of service data
when data were
collection
collected during
previous 6-month
period, plus updates to
protocol
10.5. Report updates to data collection
2/28/2014 (Semiannual**)
DOH/Ambros
Not started
Document describing
protocol and instances of quality data
when data were
collection
collected during
previous 6-month
period, plus updates to
protocol
10.6. Report updates to data collection
2/28/2014 (Semiannual**)
DOH/Ambros
Not started
Document describing
protocol and instances of outcomes
when data were
measures collection
collected during
previous 6-month
period plus updates to
protocol
** If States do not submit satisfactory information regarding data collection protocol, they will be required to submit this information on a quarterly basis.
8
SUSTAINABILITY
11. States should identify funding sources that will allow them to build and maintain the required structural changes.
Major Objective / Interim Tasks
11.1. Identify funding sources to implement
the structural changes
Suggested Due Date
(from time of Work Plan
submission)*
8/30/2013 (submit with
Work Plan)
11.2. Develop sustainability plan
8/31/2014
Lead Person
DOH/Ambros
DOH/Ambros
Status of
Task
Completed
Updates as
necessary
will be done
quarterly
Not started
Deliverables
Description of funding
sources
Funding sources and
estimated annual
budget necessary to
maintain structural
changes after award
period ends
9
Major Objective / Interim Tasks
11.3. Describe the planned usage for the
enhanced funding
Suggested Due Date
(from time of Work Plan
submission)*
8/30/2013 (submit with
Work Plan)
Lead Person
Status of
Task
Deliverables
DOH/Ambros
Completed
Description of how the
State will use the
enhanced funding
earned through the
program. Detail how
these planned
expenditures: 1.
Increase offerings of or
access to noninstitutional long-term
services and supports; 2.
Are for the benefit of
Medicaid recipients; and
3. Are not a prohibited
use of Medicaid
funding.
EXCHANGE IT COORDINATION
12. States must make an effort to coordinate their NWD/SEP system with the Health Information Exchange IT system.
Major Objective / Interim Tasks
12.1 Describe plans to coordinate the
NWD/SEP system with the Health
Insurance Exchange IT system
Suggested Due Date (from
time of Work Plan
submission)*
4/1/2014
Lead Person
Status of
Task
DOH/Ambros
SOFA/Kitazawa
Not started
Deliverables
Description of plan of
coordination
10
Major Objective / Interim Tasks
12.2 Provide updates on coordination,
including the technological
infrastructure
Suggested Due Date (from
time of Work Plan
submission)*
2/28/2014 (Semiannual )
Lead Person
Status of
Task
DOH/Ambros
SOFA/Kitazawa
Not started
Deliverables
Description of
coordination efforts
HOUSING OPTIONS (NY)
13. The State should build community-based housing options for the Intellectual Disability/Developmental Disability (ID/DD)
population and support transitions.
Major Objective / Interim Tasks
13.1. Describe all settings in which the ID/DD
population currently resides
Suggested Due Date (from
time of Work Plan
submission)*
8/30/2013 (submit with
Work Plan)
Lead Person
Status of
Task
Deliverables
OPWDD/Marlay
Completed
Completed
Description of settings
where OPWDD
population resides
Description of strategy,
including a timeline of
transitions
Description of process
Refer to Appendices H,
OPWDD
Developmental
Disabilities
Transformation
11/30/2013 Deliverable
13.2. Describe a strategy for building housing
options for the ID/DD population
8/30/2013 (submit with
Work Plan)
OPWDD/Marlay
13.3. Describe the process the State will use
to determine whether residential
settings for persons transitioned from
institutions meet Centers for Medicare
and Medicaid Services (CMS) standards
for home and community-based
settings and/or qualify as residences in
the Money Follows the Person (MFP)
program
11/30/2013
OPWDD/Marlay
Completed
11
Major Objective / Interim Tasks
13.4. Provide updates on transitions from
institutional settings to community
settings for the ID/DD population
Suggested Due Date (from
time of Work Plan
submission)*
2/28/2014 (semiannual )
Lead Person
Status of
Task
Deliverables
OPWDD/Marlay
Not started
Description of progress
and number of
transitions
12
DESCRIPTIONS OF DELIVERABLES AND COMPANION TEXT
1.
All individuals receive standardized information and experience the same eligibility
determination and enrollment processes.
1.1. Develop standardized informational materials that NWD/SEPs provide to individuals: Informational
materials can include pamphlets, summaries of programs and related eligibility criteria, and case
worker scripts. States may already have developed these materials and distributed them to
individuals seeking community LTSS.
Describe the current status of this task:
Existing materials available across partnering entities will be reviewed (e.g., brochures,
summaries of programs and eligibility criteria). Standardized package will be assembled for
distribution to individuals, families, and caregivers. New brochures, fact sheets etc. will be
developed as necessary.
Each existing NY Connects program adheres to State Standards on operations and
implementation protocols. These standards are currently being updated by SOFA and the draft
will be shared with the No Wrong Door/Single Entry Point (NWD/SEP) work group for
review/comment to assure coordination and consistency across the expanded NY Connects
Network of NWD/SEPs.
Existing training for Information and Assistance Specialists, developed by the University at
Albany, State University of New York, Center for Excellence in Aging and Community Wellness,
will be reviewed by work group. This training focuses on initial contact with individual/family
member/caregiver, person-centered approach, screening and problem-solving. Updated
training with additional modules related to needs and concerns of specific populations will be
developed and delivered to all staff at the NWD/SEPs.
Describe experienced or anticipated challenges to completing this task:
Preliminary package expected to be available by 6/15/14. Some materials will need to be
amended or replaced as the NY Connects Network of NWD/SEPs is expanded statewide,
contracts are awarded for additional partners to comprise the Network, the 1-800-telephone
number becomes available, and as various reform initiatives are implemented related to
eligibility determination and enrollment processes.
Determining if one set of standardized information will be useful across all populations while
retaining ease of use by individuals and families.
Describe the State’s plan to address the challenges described above:
The Uniform Resource Locators (URLs) for the NY Connects Resource Directory, myBenefits
and other useful sites will be part of the standardized information package. A general
informational brochure will be revised when the 1-800 telephone number is available, and
whenever else appropriate. Interagency work group will convene to review materials as needed
to keep updated. Determination will be made if one standardized package works across all
populations or if supplemental materials will be provided for specific populations as
appropriate.
13
1.2. Train all participating agencies/staff on eligibility determination and enrollment processes: All staff
should be trained on these processes by the time the NWD/SEP system is implemented for
testing (18 months after date of Work Plan submission). This timing corresponds to an
automated NWD/SEP system; the implementation of a paper-based system should require less
time. As a related deliverable, States should submit the training documents used by NWD/SEP
staff to follow the NWD/SEP processes, in addition to the training agenda. To be effective,
documents should include flow diagrams and clear guidelines for each type of NWD/SEP staff
member.
Describe the current status of this task:
DOH will take the lead on training on Medicaid eligibility, determination and enrollment
processes for consistent knowledge to create seamless linkages. OPWDD will provide
information on agency eligibility determination process for incorporation of overall training.
Currently, Local Department of Social Services (LDSS) performs the training function for NY
Connects staff regarding eligibility and enrollment processes and/or the LDSS staff is co-located
or virtually connected with the Area Agencies on Aging (AAA) to form the local NY Connects
program. Note: Most NY Connects programs are embedded with the AAA, some are embedded
with the LDSS and/or Community Alternative Systems Agency (CASA). NWD/SEP staff will
also be trained to initiate and coordinate the collection of Level II assessments as set forth in the
CSA work plan.
Describe experienced or anticipated challenges to completing this task:
Depending on decisions made as to best way to deliver training, there may be contracting
processes to adhere to impacting timelines. Need to determine most cost-effective and efficient
way to deliver training on an on-going sustainable basis; as well as assure consistency across
NWD/SEPs.
Staff will need to be trained to use the new and enhanced systems, technology and processes
associated with reforms under Balancing Incentive Program (BIP) and other simultaneous
reform activities (i.e., Medicaid Managed Care, centralization of Medicaid eligibility
determinations etc.) The State will takeover eligibility function over time.
Describe the State’s plan to address the challenges described above:
Interagency work group will be identified and convened for planning and implementation.
Existing appropriate training models and modules will be leveraged that are already in
existence, such as the Uniform Assessment System-New York (UAS-NY), and training
developed as needed.
2.
A single eligibility coordinator, “case management system,” or otherwise coordinated process
guides the individual through the entire functional and financial eligibility determination
process.
2.1. Design system (initial overview): The State should submit with the Work Plan a general description
of the NWD/SEP system, including the major actors (i.e., Operating Agency, NWD/SEPs),
overview of processes (e.g., flow diagram), and the level of automation expected within the
14
system. For example, States should indicate whether they plan on using an online Level I screen
and/or an automated Level II assessment that feeds into a central database, accessible to all
NWD/SEPs.
The BIP oversight and operating agency is DOH. New York State (NYS) will expand the current
NY Connects programs operational in 54 counties across NYS to cover the entire State and
enhance NY Connects by partnering with other systems consistently across the State to form the
NY Connects Network of NWDs/SEPs. The current NY Connects program is comprised of the
AAA and LDSS. The organizational structure varies by county and may have co-located staff
from both these agencies, be located in one agency and coordinate as necessary or are “virtually”
connected. The lead NY Connects local agencies are required to have a Memorandum of
Understanding (MOU) specifying roles and responsibilities. There are a variety of local partners
involved in NY Connects and that serve on the Local Term Care Council (LTCC), including
Community Based Organizations (CBOs) serving people with disabilities, such as Independent
Living Centers (ILCs), with some members of the ILCS designated as chair of the LTCC.
Through BIP, the ILCs and CBOs (where the ILC does not have area coverage) will have an
opportunity to formally become part of NY Connects to assure a strong local partnership
referral, information and assistance source for younger individuals with disabilities.
Through the expansion and enhancement of NY Connects to form the NY Connects Network of
NWDs/SEPs (NY Connects Network), individuals with disabilities of any age, older adults and
caregivers that may be in need of long term services and supports (LTSS) will be able to receive
information and assistance about available LTSS operating in accordance with consistent
Standards and Operating Protocols, Level I screen, application assistance for Medicaid and other
publicly funded programs as appropriate linkage to available services for non-Medicaid
eligibles, and assistance in being linked to appropriate Level II assessment (financial and
functional) when the Level I screen shows the individual may potentially be eligible for
Medicaid community based LTSS. Individuals will be able to receive assistance through the
website, a 1-800 number or in person at the NWD office in the community or person’s home.
• The NY Connects Network potentially include the existing NY Connects (ADRC)
programs, Regional Resource Development Centers (RRDCs), Developmental
Disabilities Regional Offices (DDROs), OMH Regional Field Offices and it is anticipated
that there will be a Request for Proposal (RFP) to contract directly with ILCs and/or
CBOs representing individuals with disabilities.
• Individual/caregivers will be able to access the NY Connects Network and
comprehensive, objective information and assistance through the website, a statewide 1800 telephone number that will be a virtual call center (routing calls to the NWD/SEP
within the zip code of the person needing information about or in need of LTSS); or in
person at the NWD/SEP, in the community or in the person’s home.
• The NWDs/SEPs will coordinate across the Network of NWD/SEPs to minimize the need
for “hand- offs” of individuals/caregivers to assure a seamless process. Staff will be
trained to provide consistent information and assistance about available services,
operate in accordance with Standards and Operating Protocols, conduct Level I screens
as appropriate and, perform job utilizing person-centered approaches, provide
application assistance for Medicaid and other publicly funded programs as needed,
provide linkages to available services for individuals not eligible for Medicaid, and to
15
initiate and coordinate the collection of Level II assessments as set forth in the CSA work
plan when Level I screen shows potential eligibility for Medicaid Community LTSS.
The data will be funneled to an accessible central database.
• The current vendor contract for the NY Connects Resource Directory expires February,
2014. SOFA is currently working on a RFP to procure an IT solution for a searchable
provider database for the public and information about services and programs.
Currently local NY Connects programs are responsible for inputting and maintaining
provider data in their service region in accordance with NY Connects Resource
Directory business rules, style guide and inclusion/exclusion policy. The State retains
ability to override. The back end of the NY Connects Resource Directory is accessible to
the NWD/SEPs. The new RFP will seek interoperability or interface among NY
Connects Network partners to be able to share information from a Level I screen and
services provided as needed and appropriate.
• The www.nyconnects.ny.gov website links to www.mybenefits.ny.gov, which provides
an automated screen for programs and services for which the individual may be eligible.
Work will be undertaken to determine if this meets the criteria for an automated Level I
screen, or linked to a Level I screen for eligibility for LTSS or whether an automated
system is feasible.
• An important component of the existing NY Connects design is the required Local Long
Term Care Coordinating Councils (LTCCCs). The Councils are comprised of local
governmental partners, community based organizations and service providers, hospitals
and other institutional and community based medical providers, consumers/caregivers.
Currently, there are almost 1,600 stakeholders participating on the Councils across the
State. Several of the LTCCCs are chaired or co-chaired by ILCs. With the expansion and
enhancement of NY Connects to the NY Connects Network, the LTCCCs will also be
required to have participation from the mental health and Intellectual Disability and/or
Developmental Disability (ID/DD) networks. Currently, some of the LTCCCs already
have this representation on the Council. The LTCCCs are charged with assessing the
LTSS needs of the community, identifying priorities to address, and develop an action
plan. Examples of LTCCC efforts include improving transportation coordination,
facilitating better communication and coordination between health and community
providers and improving services availability and accessibility.
• See accompanying person flow diagram – Appendix A.1
Describe the current status of this task:
The BIP NWD/SEP work group has been meeting regularly to think through the best way to
coordinate the various systems to create a user friendly, streamlined network of NWDs/SEPs,
building upon the existing NY Connects program and adding NWD access partners. This State
cross-systems group will continue meeting to fully develop and implement the NY Connects
Network statewide to be accessed by individuals and caregivers of all ages in need of long term
services and supports, regardless of payer source, diagnosis or disability. Discussions include
the use of technology to create a virtual call center and appropriate access by NWD/SEP staff (in
accordance with Health Insurance Portability and Accountability Act (HIPAA) compliance,
confidentiality etc.), to information from the Level I screen, when and how a “hand-off” should
16
occur, what will happen to individuals not eligible for Medicaid, and other identified issues.
Describe experienced or anticipated challenges to completing this task:
•
•
•
Coordinating multiple, large systems to achieve person-centered approaches.
Implementing technological solutions in a timely manner.
Promise of technology being realistic (i.e. interoperability and interfaces among
disparate systems).
• Bridging philosophical differences in different systems.
• Confidentiality.
• Overall complexity.
Describe the State’s plan to address the challenges described above:
Interagency NWD/SEP work group will regularly meet. Given overlap of work among the
various work groups established for the BIP initiative, it is expected that members will crosspopulate the work groups at the appropriate times.
In addition, the BIP NWD/SEP work group will bring in people with technical expertise in
information technology to advise on the next phase of planning.
2.2. Design system (final detailed design): This second task involves a much more detailed design
structure of the NWD/SEP system. If the State plans to contract a vendor to build an automated
system, the deliverable associated with this task will be a Request for Proposals (RFP)
disseminated to potential vendors. The RFP should include the data flow, highlighting which
entity(ies) will house the data, data transfer mechanisms, levels of user access, and data security
measures. If the NWD/SEP system is paper-based, the description should include how
information will be transferred to different participating entities in a timely manner (e.g. phone,
fax) and how non-electronic data will be stored and retrieved securely.
Describe the current status of this task:
In progress.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
2.3. Select vendor (if automated): Once a vendor is selected to build or enhance the NWD/SEP system,
the State should submit a memo indicating the vendor name and qualifications (i.e., reason for
selection).
Describe the current status of this task:
Not started.
17
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
2.4. Implement and test system: We expect many States will gradually roll out the NWD/SEP system,
incorporating NWD/SEPs one at a time or in groups. This will allow States to test processes,
identify lessons learned, and make improvements. This task requires a description of the rollout plan, including which entities will implement the system when, and protocols for evaluating
processes and incorporating lessons learned.
Describe the current status of this task:
Not Started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
2.5. System goes live: Once the system is live or fully operational, States should submit a memo to
CMS indicating that it is fully operational and describe any major system changes implemented
since the detailed design.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
2.6. System updates: After the system goes live, States should submit a brief semiannual report
describing the successes and challenges associated with the system.
Describe the current status of this task:
Not started.
18
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
3.
State has a network of NWD/SEPs and an Operating Agency; the Medicaid Agency is the
Oversight Agency.
3.1. Identify the Operating Agency: The name of this agency should be included in the initial
description of the NWD/SEP system.
Describe the current status of this task:
Completed. NY State Department of Health (DOH) is the Operating Agency.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
3.2. Identify the NWD/SEPs: The names of the entities and their locations should be included in the
initial description of the NWD/SEP system.
Describe the current status of this task:
See Appendix A.2.
NY Connects will be the platform to implement the required NWD/SEP element of BIP.
NYSOFA, DOH, OPWDD and the OMH are working together to develop the necessary plans to
expand and enhance NY Connects to become the NY Connects Network. Other partners will be
added as expansion rolls out and RFA, RFP and contracting processes are finalized.
Currently there are 53 NY Connects Programs covering 54 counties; LDSS in each county and
Human Resource Administration (HRA) in New York City (NYC), Area Agencies on Aging
covering every county and NYC Department for the Aging (DFTA) in NYC, RRDCs, DDROs,
and OMH Field Offices. At this point, the State is reviewing a procurement strategy to contract
with additional partners to form the expanded NY Connects Network of NWDs/SEPs which will
be targeted to ILCs and other appropriate CBOs representing individuals with disabilities to
achieve statewide coverage.
Describe experienced or anticipated challenges to completing this task:
•
Getting potential NWD/SEPs which are not already in the NY Connects to understand
the requirements, evaluate their organizations capacity to meet the requirements, and
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making the commitment in a short period of time.
•
Contracting processes; issuance of an RFA and RFP to determine rest of complement of
NWD/SEPs comprising the Network.
•
Completing deliverables in required time frame/meeting the time table.
Describe the State’s plan to address the challenges described above:
Developing concise communication materials to allow potential NWD/SEPs to understand the
requirements and make the commitment.
Establishing long range meeting schedule of interagency work group to meet deliverables.
3.3. Develop and implement a Memorandum of Understanding (MOU) across agencies, including the State
Medicaid Agency and the Operating Agency: Given that many agencies will be involved in the
NWD/SEP system, it is essential that each agency has a clear role and is on board with
completing its responsibilities. MOUs are a key resource in helping define tasks and develop or
solidify support. An example MOU is located in Appendix F in the Manual.
Describe the current status of this task:
In progress. Information gathering has begun.
Describe experienced or anticipated challenges to completing this task:
The various approval processes for each of the entities involved in BIP may make it difficult to
implement an MOU in a timely manner.
Describe the State’s plan to address the challenges described above:
Leverage the priority processes that have been established with approval authorities.
4.
NWD/SEPs have access points where individuals can inquire about community LTSS and receive
comprehensive information, eligibility determinations, community LTSS , community LTSS
program options counseling,, and enrollment assistance.
4.1. Identify service coverage of all NWD/SEPs: As previously noted, NWD/SEP’s services cover all
residents within a certain distance. Ideally, the combined services of all NWD/SEPs should
cover the State’s entire population. Because this is not always feasible, States should submit the
percentage of the State’s population actually covered by the NWD/SEP and a description of why
100 percent coverage is not feasible.
Describe the current status of this task:
NY Connects works as a coordinated system of information, assistance, and access for New
Yorkers seeking long term services and supports information and assistance. Currently there are
53 programs covering 54 counties. With BIP, the ILCS or CBOs serving individuals with
disabilities will be offered an opportunity to contract with the State, through an RFP process, to
20
partner with the NY Connects Network.
The date for New York to achieve 100 percent coverage for the State has been amended to
1/1/2015. Work is already underway to bring the non-participating counties formally into the
NY Connects Program. By March 1, 2014, a letter will be sent to all currently non-participating
counties, extending an offer to participate in the NY Connects program. If a county decides not
to participate in the program, a Request for Proposal will be issued to select an entity to
administer the NY Connects Program in that area. This expansion of NY Connects in concert
with the other NWD/SEP partners (see Appendix 2-A) to form the NY Connects Network of
NYSs/SEPs will provide 100 percent service coverage. Expanding the geographic and human
resource capacity, along with the necessary technological solutions, will enable a seamless and
more timely experience for potentially eligible Medicaid individuals/Medicaid recipients in need
of LTSS regardless of age, disability or diagnosis; as well as comprehensive information and
assistance and linkage to services for individuals not eligible for Medicaid.
New York does not see a need to develop a mitigation plan as there is an expectation that the
State will meet this deliverable by 1/1/2015.
Describe experienced or anticipated challenges to completing this task:
•
Needing to issue an RFP and RFA to determine full complement of NWD/SEPs; which
will likely impact rollout timeframes.
•
Coordinating multiple, large systems to achieve person-centered approaches as well as
standardized implementation of NWD/SEP functions.
•
Implementing technological solutions in a timely manner.
•
Promise of technology being realistic (i.e. interoperability and interfaces among
disparate systems).
•
Bridging philosophical differences in different systems.
•
Confidentiality.
•
Overall complexity.
Describe the State’s plan to address the challenges described above:
Interagency work group will work through challenges and BIP State Team will assist in
problem-solving as needed.
4.2. Ensure NWD/SEPs are accessible to older adults and individuals with disabilities: States should
indicate the features of the NWD/SEPs that promote accessibility, including wheelchair ramps,
proximity to public transportation, bilingual staff, etc.
Describe the current status of this task:
All NY Connects programs are required to provide free language accessibility services to those
with limited English proficiency.
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NY Connects programs can conduct home visits if an individual is unable to make a visit to the
NY Connects program and wishes to speak to an Information and Assistance Specialist/Options
Counselor in person.
In addition, New York is exploring the use of TTY (Text-Telephone device for the hearing
impaired) to fully serve those who are deaf, hearing impaired, or have speech difficulties.
Where the NY Connects programs currently exist, they can be accessed by telephone, face to
face, and in the home.
Describe experienced or anticipated challenges to completing this task:
Identifying the standard for accessibility.
Area Agencies on Aging (AAA) must comply with federal, state and local laws, regulations, and
issuances including the Americans with Disabilities Act of 1990, Title VI of the Civil Rights Act
of 1964, Section 504 of the Rehabilitation Act of 1973, Older Americans Act, 45 CFR Part 1321, 45
CFR Part 84 (Nondiscrimination on the basis of Handicap), Executive Order 13166 (Improving
Access to Services for Persons with Limited English Proficiency, Article 15 of the New York State
Executive Law (Human Rights Law), New York State Elder Law and Office for the Aging Rules
and Regulations Parts 6651 through 6656, and New York State Office for the Aging Equal Access
to Services and Targeting Policy (12-PI-08).
The NY Connects Standards explicitly state the following:
•
NY Connects must ensure that core functions are provided in a culturally and
linguistically appropriate manner. Consumers with special needs will be linked to
appropriate services to ensure full access to services, as applicable. NY Connects must
provide barrier-free access to its services that accommodates people with special needs
and access for consumers who speak languages other than English.
•
NY Connects must provide educational materials that are culturally and linguistically
sensitive, at a maximum sixth grade level of readability, and can be accessed by
individuals with special needs.
•
NY Connects must demonstrate the capacity to conduct on site visits including visiting a
consumer residence, outpatient setting, acute care facility, or any other setting that will
best accommodate consumer needs in accordance with this standard. Should the NY
Connects Program determine the need for an off-site visit to provide information and
assistance, then such off-site visits must be made within three working days.
Compliance with federal, state, and local laws, and NY Connects standards will be required for
all entities participating in the NY Connects Network and the three modes of contact with NY
Connects. This will include:
•
•
•
NY Connects website is 508 compliant;
The toll-free number being established for the program will have TTY capability and
language accessibility services; and
Direct client contact may take place in the NY Connects office, in the community, or in
the client’s home.
22
Describe the State’s plan to address the challenges described above:
Recognizing the need for an interagency work group and identifying the people with the right
skill sets to develop the standard and assure its implementation.
5.
The NWD/SEP system includes an informative community LTSS website; Website lists 1-800
number for NWD/SEP network.
5.1. Identify or develop URL: Many States already have websites with information on community
LTSS. If the State plans to use a website already in existence, it should submit the URL of that
website.
Describe the current status of this task:
The URL is: www.nyconnects.ny.gov
Describe experienced or anticipated challenges to completing this task:
Current vendor contract for the NY Connects Resource Directory expires February, 2014.
Describe the State’s plan to address the challenges described above:
In compliance with contracting requirements, and the expansion and enhancement of NY
Connects, SOFA is currently working with the NYS Office of Information Technology on a RFP
to procure a solution for a searchable provider database for the public and information about
services and programs. Currently local NY Connects programs are responsible for inputting
and maintaining provider data in their service region in accordance with NY Connects Resource
Directory business rules, style guide and inclusion/exclusion policy. Since the launch of the
website, efforts have continued to be made to grow the site including LTSS across the multiple
systems. The back end of the NY Connects Resource Directory will be accessible to the
NWD/SEPs. The new RFP will seek interoperability or interface among NY Connects Network
partners to be able to share information from a Level I screen and services provided as needed
and appropriate.
The original RFP and development of site was performed in collaboration with DOH. OPWDD
and OMH provided input prior to initial launch. An interagency team will assist in the
transition efforts.
23
5.2. Develop and incorporate content: The State should incorporate additional information into its
website as necessary. Once the website is completed, the State should submit the URL for CMS
to review.
Describe the current status of this task:
New York will continue to add providers/ services to the NY Connects Resource Directory.
NYC DFTA is currently under contract to identify and upload LTSS services and providers
serving NYC (which meet SOFA requirements) into the Resource Directory. The current vendor
contract expires February 2014. SOFA, with the assistance of, the Office of Information
Technology Services Human Services Cluster, is currently in the process of developing an RFP
for a solution for a searchable provider database for the public, as well as information about
services and programs. Currently NY Connects programs responsible for inputting provider
data in service region in accordance with NY Connects resource directory business rules, style
guide and inclusion/exclusion policy, although SOFA retains the ability to override. The back
end of the Resource Directory will be accessible to the NWD/SEPs. New RFP will also seek
interoperability or interface among NY Connects partners.
The NWD/SEP work group members will be invited to participate in some of the RFP
development discussion and/or review and comment on draft documents. Additional resources
with information technology expertise will be brought into the work group as needed.
Describe experienced or anticipated challenges to completing this task:
Complexity of keeping website content up-to-date and consistent.
Describe the State’s plan to address the challenges described above:
Interagency Team will review and update, as necessary, the NY Connects resource directory
business rules, style guide and inclusion/exclusion policy as well as implement additional
protocols to expand and enhance content adhering to security requirements and maintaining
accuracy.
5.3. Incorporate the Level I screen into the website (recommended, not required): If the State chooses to
incorporate a Level I screening tool into its community LTSS website, it should submit the
working URL of the tool, in addition to the instructions for users to complete the screen.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
24
6.
Single 1-800 number where individuals can receive information about community LTSS options in
the State, request additional information, and schedule appointments at local NWD/SEPs for
assessments.
6.1. Contract 1-800 number services: Many States already have 1-800 numbers for providing
information on community LTSS. If the State plans to use a number already in existence, it
should submit that phone number. If not, it must describe its method for developing or
contracting a 1-800 number service and indicate when the number is functioning.
Describe the current status of this task:
New York is exploring options to implement a statewide 1-800 number, including the use of
TTY.
Describe experienced or anticipated challenges to completing this task:
Need to have the expanded network of NWDs in place and trained before implement the 1-800
number service.
Describe the State’s plan to address the challenges described above:
Execute contract, perform testing, and prepare for launching of 1-800 number service to coincide
with NY Connects Network launch statewide.
6.2. Train staff to answer phones, provide information, and conduct the Level I screen: NWD/SEP staff must
be trained on how to provide information and conduct assessments in a standardized fashion.
The State should submit related training materials and schedules.
Describe the current status of this task:
Not started.
However, there is existing training for Information and Assistance Specialists at the existing NY
Connects programs, developed by the University at Albany, State University of New York,
which will be reviewed by work group. This training focuses on initial contact with individual/
family member/caregiver, person-centered approach, screening and problem-solving. Updated
training with additional modules will be developed and delivered to all staff at NWD/SEP.
Describe experienced or anticipated challenges to completing this task:
Depending on decisions made as to best way to deliver training, there may be contracting
processes to adhere to impacting timelines. Need to determine most cost-effective and efficient
way to deliver training on an on-going sustainable basis; as well as assure consistency across
NWDs/SEPs.
25
Describe the State’s plan to address the challenges described above:
Interagency work group will be identified and convened for planning and implementation.
Existing appropriate training models and modules will be leverage that are already in existence.
Additional experts will be brought in as needed.
7.
State advertises the NWD/SEP system to help establish it as the “go to system” for community
LTSS
7.1. Develop advertising plan: Nursing homes, hospitals, community-based organizations, medical
providers, and other governmental social programs should be aware of and refer clients to the
NWD/SEP system. Therefore, the State must develop and submit a plan for advertising the
system to all potential referring partners.
Describe the current status of this task:
Currently, all NY Connects programs are required to conduct public education to educate the
residents of the community on the availability of NY Connects. NY Connects programs must
provide education to the general public, as well as targeted stakeholders, including hospitals,
community based organizations, medical providers, who may serve as conduits to the long term
services and supports system.
Describe experienced or anticipated challenges to completing this task:
Need to have statewide coverage and staffing capacity by the NY Connects Network before a
public education/advertising plan is launched to be able to respond to the dramatic increase in
the influx of calls that will likely result from the public education campaign.
Describe the State’s plan to address the challenges described above:
The NY Connects Network will be rolled out and a team or contractor will develop an
advertising plan to launch across the State when the Network is operational and staffing is in
place statewide.
7.2. Implement advertising plan: To indicate that the advertising plan has been implemented, States
should submit related materials, such as posters and pamphlets.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
26
8. A CSA, which supports the purposes of determining eligibility, identifying support
needs, and informing service planning, is used across the State and across a given
population. The assessment is completed in person, with the assistance of a qualified
professional. The CSA includes a CDS (a Core Data Set of required domains and topics).
8.1. Develop questions for the Level I screen: The Level I screen should include a series of basic
financial and functional questions that indicate whether a person may be eligible for
Medicaid-funded community LTSS. States must identify and submit these questions.
Many will submit a Level I screen already in use.
Describe the current status of this task:
This task is in progress. The Level I screen for all is being developed in conjunction with the
process analyses currently being conducted for the NWD/SEP network.
Describe experienced or anticipated challenges to completing this task:
Identifying a Level I screen that will work across populations with a minimum number of
questions.
Behavioral health questions have not traditionally been included and will require development.
Describe the State’s plan to address the challenges described above:
The State will test the screen vs. “# of questions” trade off via case studies representing
individuals from all populations.
The State will explore options for optimizing the design of the Level I screen to incorporate
hierarchal stopping points using the order of the questions.
The OMH will use other State models to help incorporate the behavioral health perspective.
8.2. Fill out CDS crosswalk to determine if State’s current assessments include required domains and
topics: Refer to Appendix H in the Manual for instructions on how to determine if the
assessment already in use has all required domains and topics within the CDS. An
electronic version of the CDS crosswalk can be found on the Balancing Incentive
Program technical assistance website at:
http://www.balancingincentiveprogram.org/resources/crosswalk-between-corestandardized-assessment-csa-and-core-dataset-cds.
Describe the current status of this task:
Completed. See attached appendices B.1 through B.6.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
27
Describe the State’s plan to address the challenges described above:
Not applicable.
8.3. Incorporate additional domains and topics if necessary (stakeholder involvement is highly
recommended): Many States already use assessments that include all of the required
domains and topics within the CDS. If not, the State should incorporate additional
domains and topics using input from stakeholders. For the required deliverable, the
State should submit the final assessment in addition to any materials that indicate
stakeholder involvement.
Describe the current status of this task:
In progress.
The State is currently implementing a UAS-NY using the interRAI suite tools for the elderly and
physically disabled population which contain the domains and topics in CMS’s CDS.
The State is currently piloting an instrument developed by interRAI and the OPWDD for the
ID/DD population. While this instrument is not final yet, it includes all the required domains
and topics in CMS’s CDS and the State is highly confident that any changes which may be
revealed by the pilot will not impact the status of the instrument in terms of its containing the
domains and topics in CMS’s CDS.
The State has decided on interRAI’s Community Mental Health Assessment instrument for the
adult Behavioral Health/Mental Health (BH/MH) population.
The State will continue to use the Child and Adolescent Needs and Strength (CANS-NY) for
children entering the Home and Community Based Services (HCBS) Waiver. The CANS-NY
meets all domains and topics currently required for CMS’s CDS.
Stakeholder Involvement:
For the elderly and physically disabled population served by DOH, stakeholder involvement
began with a Request for Information (RFI) released and published in 2007 and continued with
the Long Term Care Advisory Committee for the duration of its existence. Once the instruments
that best met DOH goals became apparent, the DOH hosted a 2 hour meeting and presentation
by interRAI principal Brant Fries and fellow Mary James for the Committee. Committee
members, which included representation from the spectrum of stakeholders, were able to ask
questions and affirm the interRAI suite of instruments were the best fit for individuals,
providers and agencies.
For the population served by OPWDD, domains assessing individual’s strengths, social
relationships and supports as well as items reflective of individual goals and desire for change
are incorporated into the Coordinated Assessment System (CAS), the piloted instrument.
Approximately 400 individuals (stakeholders) from nineteen provider agencies have been
assessed utilizing the CAS. Input from these individuals and agency stakeholders will be sought
and a validity study of the tool will be commenced. Upon completion of the pilot review and
28
the validity study the CAS will be finalized.
The Community Mental Health instrument for adults is being influenced by the public Medicaid
Redesign Team (MRT) processes.
There was stakeholder involvement in the development of the CANS-NY algorithm. John
Lyons, PhD. (author) met with OMH State staff, OMH Field Office staff and staff from St. Luke's
Hospital (Children’s Single Point of Access (C-SPOA)) in finalizing the CANS-NY algorithm.
The development of CANS-NY was a collaborative effort between the Office of Children and
Family Services (OCFS), OMH and John Lyons in combining the CANS-MH and the CANS-B2H
so waiver providers were not directly involved in its development.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
8.4. Train staff members at NWD/SEPs to coordinate the CSA: NWD/SEP staff must be trained
to initiate and coordinate the collection of Level II assessments. This involves working
with the clinical staff responsible for actually conducting the assessment and ensuring
the assessment is completed in a timely fashion. Once again, States should submit
training materials and schedules associated with this task.
Describe the current status of this task:
For the elderly and physically disabled population served by DOH, the web-based training
curriculum and courses were co-developed by experts in education and& training and
Registered Nurses (RNs). In addition, the web based training courses for the Level II
assessments were tested by RN’s and social workers in the field during the BETA test of the
UAS-NY in the spring of 2012. These activities began long before the BIP application was
approved, but since the training is web-based and it currently involves many of the
organizations which have been identified as SEP’s, it is anticipated the statewide training for the
NWD/SEP members to initiate and coordinate the collection the Level II assessments for the
elderly and physically disabled population can be completed by 8/15/14.
The OPWDD hired and trained sixteen staff to complete the pilot phase of the tool. Additional
staff will need to be hired and trained for the implementation of the validity study and for the
initial phase-in of the tool. Contracting for the development of rigorous training modules to be
integrated into the UAS-NY will need to begin. Draft work plans for the State’s responsibilities
in regards to timely coordination and completion of the Level II assessment are currently in
progress. It is anticipated the NWD/SEP members can be trained to initiate and coordinate the
collection of the OPWDD Level II assessment by 8/15/14.
For the OMH HCBS Waiver, all associated staff that participate in the referral, assessment and
plan of care process will be trained on the changes by 8/15/14; the associated participants are
already trained and certified in the use of the CANS-NY. Very minor adaptations to the current
29
process will be necessary to bring it more consistently in line with BIP requirements.
An OMH/Office of Alcohol and Substance Abuse Services (OASAS) training design is in the
planning stage with anticipated completion for the NWD/SEP members to initiate and
coordinate the collection of OMH Level II assessments by 8/15/14.
Describe experienced or anticipated challenges to completing this task:
As set forth above, the automation and training for the Level II assessments are in varying
degrees of completion. This complicates training for initiating and coordinating the collection of
the OPWDD Level II assessment.
As the various instruments evolve and are integrated in one system, so will the content of the
training. This will hold true for the content of both coordinating and conducting assessments
and system navigation.
An investment is required to develop and integrate training on the OPWDD Level II instrument.
Potential contracting delays would challenge the delivery of the training modules integrated
into the UAS-NY system.
For the OMH HCBS Waiver, analysis of needed resources to enhance existing processes needs to
be completed. Investment is also needed to integrate training for the OMH Level II instruments.
Describe the State’s plan to address the challenges described above:
The State will align training for the Level I screen as set forth in the NWD/SEP work plan with
the training for the initiation and coordination of the Level II assessment for NWD/SEP members
as these processes are naturally connected.
The State will build on the web-based training already developed for those served by the DOH.
The web-based training is self-paced and available 24/7 and so provides maximum availability
and flexibility.
The OPWDD intends to contract with the external expertise in training development utilized by
DOH to leverage existing resources. To minimize contract delays for the Level II assessments,
the State would seek to contract through an MOU process.
The OMH will also evaluate how to leverage existing resources.
8.5. Identify qualified personnel to administer the CSA: States should submit a list of entities
responsible for conducting the different portions of the assessment in addition to their
qualifications, such as certification, education, or training.
Describe the current status of this task:
In progress.
Staff qualifications
The DOH requires UAS-NY nurses to complete assessments. The system also allows those with
30
other disciplines such as social workers and therapists to directly contribute to assessments
before they are completed by a nurse.
The OPWDD selected the initial assessment personnel from a pool of OPWDD staff whose
current job requirements were similar in scope and whose positions would be requiring eventual
re-assignment within the agency. Required qualifications: Bachelor’s degree or higher in social
work or in a human service field, one year post-bachelor’s degree experience working with
individuals with ID/DD, experience conducting interviews or assessments, and experience
adapting interview skills to elicit information from individuals with ID/DD and their families,
staff, and advocates.
In addition to the above requirements, OPWDD will be including licensed registered nurses as
acceptable educational criteria when hiring additional staff.
The CANS instrument is completed by the Single Point of Access (SPOA)/Local Government
Unit (LGU), a member of the SPOA team and/or the HCBS Waiver agency. Once completed, it is
reviewed and approved by the SPOA/LGU for LOC determination.
The OMH/OASAS are currently considering entities for completing assessments, including the
necessary qualifications/professional preparedness for the Community Mental Health
instrument.
Entities
Once the protocol for removing conflict free case management is established and the NWD/SEP
network has been contractually arranged, the State will submit a list of entities responsible for
conducting the different portions of the assessment, including the financial assessment and the
Level II assessment, in addition to their qualifications.
Describe experienced or anticipated challenges to completing this task:
Identifying and executing the related organizational arrangements seamlessly for conflict free
case management is seen as the challenge to training qualified professionals to conduct different
portions of the assessment.
Describe the State’s plan to address the challenges described above:
The State plans to develop its training schedule and staff qualifications in concert with the
contractual requirements of the organizations which will conduct the various parts of the
assessments.
8.6. Regular updates: After the implementation of the CSA, States should submit brief
semiannual reports with successes and challenges associated with the CSA.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
31
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
9. States must establish conflict of interest standards for the Level I screen, the Level II
assessment and, the plan of care processes. An individual’s plan of care must be created
independently from the availability of funding to provide services.
9.1. Describe current case management system: This description should identify areas of
possible conflict in case management and systems the State currently has in place to
mitigate those conflicts.
Describe the current status of this task:
NYS currently has a number of processes and policies in force to mitigate potential
conflicts of interest in the assessment and care planning process throughout the various
programs overseen by DOH, OPWDD and OMH. As we make the transition to Care
Management for All, new policies and procedures will have to be developed to ensure
that potential conflicts are mitigated and that consumers know they have both options
and recourse in the receipt of services.
Different programs have different assessment processes and care planning approaches.
For instance, in the state plan personal care program overseen by the DOH, services are
ordered by a physician but an assessment provided by local social service district or
Certified Home Health Agency (CHHA) determines the number of hours an individual
requires to meet his or her needs. It is possible that the CHHA that determined the
number of hours an individual needs could also be the service provider of the home
health aide. The State always has the ability to audit assessments. OPWDD and OMH
programs generally rely on the State staff in regional offices to determine eligibility and
perform functional assessments that inform care planning. These activities, however,
may be delegated to down-stream providers, establishing a potential conflict of interest.
As we make the transition of many programs to managed care, it is likely that similar
potential for conflict will occur. Already different plans operate differently. While
some have administrative firewalls whereby the individual who assesses the
individual’s functional need is not in the same department as the individual who
develops the care plan, and neither the assessor nor the care planner is the provider of
services, which is often an agency in the plan’s network; this is not always the case.
NYS has a strong advocate community and many procedures in place for consumers to
grieve their assessment, care plan or service concerns. Consumer choice is a paramount
concern to NYS policy makers and ensuring that individuals get the right care, at the
32
right time, in the right setting is always our goal.
The complete template in Appendix C.1 illustrates potential conflicts that may exist
across programs and agencies currently and strategies in place currently to mitigate
that risk.
Describe experienced or anticipated challenges to completing this task:
NYS is prepared for the challenge of coordinating policies across the disability services
spectrum to ensure that individuals have choices, are aware of their options, and know
how to grieve any dissatisfaction with the systems in place. State agencies will continue
to exercise oversight over the assessment, care planning and service provision processes
under BIP and will work to mitigate potential conflicts of interest. As we transition to
Care Management for All across programs and services throughout our Medicaid
supported long term care system, particular challenges will be met to ensure strong
State oversight and consumer protections are maintained.
Describe the State’s plan to address the challenges described above:
NYS plans to review existing care management plans and proposed systems to further
determine risks of potential conflict. We will continue to exercise strong State oversight
by auditing sample assessments and plans, keeping our consumer protections in place
and strengthening them where it is necessary, surveying consumers about their
satisfaction throughout the process of obtaining home/community based care and
keeping consumer choice at the forefront of our policies and procedures.
NYS is expected to eliminate some of the potential conflicts of interest that may arise in
a managed care environment by separating the initial assessment for eligibility for long
term services and supports from the assessment and care planning process. To further
address the conflict between assessment and care planning processes NYS plans to hire
a dedicated resource with expertise in organizational structures and segregation of
duties to develop options for resolution across various managed care programs. In
addition, the transition already underway in NYS to care standardized assessments
should help mitigate conflicts because care planning will be informed by data-driven,
uniform assessments administered by trained individuals and less prone to variance
borne of subjectivity.
NYS plans to review the work plans and strategies of other managed care states for
other ideas about how to reduce potential conflicts of interest that may arise during our
transition to Care Management for all.
9.2. Establish protocol for removing conflict of interest: The State must also describe how it plans
to ensure that community LTSS eligibility determination, enrollment, and case
management processes are free of conflict of interest. In this document, NY should
33
include an affirmative commitment to establish an independent process for assuring
that individual person-centered plans meet the needs of individuals served in
community-based settings, and a description of the process the State will use to assure
that person-centered plans are implemented with fidelity to the established process.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
As stated above, NYS already has safeguards in place to assure consumer choice and
adjudicate consumer complaints. However, as we transition to Care Management for
All, care must be taken to assure that entities with a financial interest in the care
provided make decisions about the care of members based solely on their assessed
needs. In addition, we have to ensure that existing safeguards are adequate to protect
consumers’ interest, as well as ensure the appropriate expenditure of Medicaid funds.
Describe the State’s plan to address the challenges described above:
As stated above the State will continue to review potential areas of conflict as this
transition unfolds and develop strategies to mitigate them. NYS is committed to
ensuring that individuals in need of long term services and supports receive them in
their chosen appropriate setting. NYS will assure that individuals’ person-centered
care plans may be provided in home/community based settings and will establish an
independent process for making sure assessed needs are met and that care plans are
implemented in a manner consistent with the process.
10. States must report service, outcome, and quality measure data to CMS in an accurate and
timely manner.
10.1. Identify data collection protocol for service data: States should submit the sources for these
data and/or the surveys that will be used to collect these data. As applicable,
information should also include sampling and data collection protocols.
Describe the current status of this task:
Completed. See Appendix D.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
34
10.2. Identify data collection protocol for quality data: States should submit the sources for these
data and/or the surveys that will be used to collect these data. As applicable,
information should also include sampling and data collection protocols.
Describe the current status of this task:
Completed. See Appendix D.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
10.3. Identify data collection protocol for outcome measures: States should submit the sources for
these data and/or the surveys that will be used to collect these data. As applicable,
information should also include sampling and data collection protocols.
Describe the current status of this task:
Completed. See Appendix D.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
10.4. Report updates to data collection protocol and instances of service data collection: On a
semiannual basis, States should submit any changes to their protocols for collecting
service data, or any new instances of service data collection.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
35
Not applicable.
10.5. Report updates to data collection protocol and instances of quality data collection: On a
semiannual basis, States should submit any changes to their protocols for collecting
quality data, or any new instances of quality data collection.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
10.6. Report updates to data collection protocol and instances of outcomes measures collection: On a
semiannual basis, States should submit any changes to their protocols for collecting
outcomes measures, or any new instances of outcomes measures collection.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
11. States should identify funding sources that will allow them to build and maintain the
required structural changes.
11.1. Identify funding sources to implement the structural changes: Before building their systems,
States must identify the sources of funding they will use to make these changes. States
should submit information on the total cost of implementing the structural changes and
the amount that each funding source will provide. Indicate how NY plans to use MFP
dollars, distinguishing between administrative and rebalancing funds, to support the
Program structural changes and a timeline for utilization.
Describe the current status of this task:
36
Completed. See Appendix E.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
11.2. Develop sustainability plan: States must also develop clear estimates of the cost to
maintain the structural changes once they are in place. Therefore, States should submit
the overall maintenance budget of the structural changes and anticipated sources of
funding.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
11.3. Describe the planned usage for the enhanced funding. The State must identify the projected
amount of funding to be earned through the Program and describe how the State will
use this enhanced funding by September 30, 2015. The State should also describe how
the planned expenditures meet the following criteria: 1. Increase offerings of or access
to non-institutional long-term services and supports; 2. Are for the benefit of Medicaid
recipients; and 3. Are not a prohibited use of Medicaid funding.
Describe the current status of this task:
Completed. See Appendix E and supplemental materials.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
37
12. States must make an effort to coordinate their NWD/SEP system with the Health
Insurance Exchange IT system.
12.1. Describe plans to coordinate systems: This may include discussions with State Exchange IT
system staff, the identification of key data fields that should be shared across the
systems, and the development of a bridge between the systems.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
12.2. Provide updates on coordination: On a semiannual basis, States should report to CMS
updates on coordination including new infrastructure developments.
Describe the current status of this task:
Not started.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
13. NY: The State should build community-based housing options for the ID/DD population and
support transitions.
13.1. Describe all settings in which the ID/DD population currently resides: This description should include
the number of individuals in group homes, small ICFs/IDD, large ICFs/IDD and non-traditional
housing models. Each setting type above should include the maximum number of individuals
living in the residence, and any type of licensure or accreditation required.
Describe the current status of this task:
Completed. Please see attachment G.1 describing settings in which the ID/DD population
currently resides including the number of individuals in group homes, group homes, small
Intermediate Care Facilities (ICFs)/IDD, large ICFs/IDD and non-traditional housing models.
This document includes the maximum number of individuals living in the residence, and any
38
type of licensure or accreditation required.
Describe experienced or anticipated challenges to completing this task:
Not applicable.
Describe the State’s plan to address the challenges described above:
Not applicable.
13.2. Describe the strategy for building housing options for the ID/DD population and supporting transitions.
This document should include NY’s plan to transition the remaining 160 residents of the Finger
Lakes and Taconic ICFs prior to December 31, 2013, to community-based settings that meet CMS
HCBS settings standards and a transition timeline for the residents of the remaining campus and
non-campus-based ICF’s.
Describe the current status of this task:
Complete. Please see attachment G.1 which describes the State’s strategy for building housing
options for the ID/DD population and supporting transitions.
Describe experienced or anticipated challenges to completing this task:
Describe the State’s plan to address the challenges described above:
13.3. Describe the process the State will use to determine whether residential settings for persons transitioned
from institutions meet CMS standards for home and community-based settings and/or qualify as
residences in the MFP program. This plan will include a description of the residential facilities, the
process the State will use to independently assess whether these settings meet the characteristics
set forth in the 1915i Notice of Proposed Rulemaking (NPRM) from April 2012, and the timeline
for compliance by all settings in which Medicaid community LTSS are provided. In this
document, NY should agree that at least 30% of those persons transitioned from institutions,
both campus-based and non-campus –based ICFs, will qualify for MFP (i.e. can be transitioned
to an MFP qualified residence), beginning in Year 1.
Describe the current status of this task:
Completed
Describe experienced or anticipated challenges to completing this task:
Refer to Appendices H, OPWDD Developmental Disabilities Transformation 11/30/2013
Deliverable
39
Describe the State’s plan to address the challenges described above:
Refer to Appendices H, OPWDD Developmental Disabilities Transformation 11/30/2013
Deliverable.
13.4. Provide semi-annual updates on progress made to developing housing options and supporting transitions.
These documents should include progress made to developing housing options and programs
that support transitions in addition to the number of transitions made.
The Work Plan should be signed by the lead of the State Medicaid Agency (the Oversight
Agency) and by the Operating Agency (if those two agencies are different).
Signature of Lead of Operating Agency
(Medicaid)
___________________________________
Name:
Agency: NYS Department of Health
Office of Health Insurance
Programs
Position: Director, Division of Long Term
Signature of Lead of Oversight Agency
______________________________________
Name:
Agency: NYS Department of Health
Office of Health Insurance Programs
Position: Direct, Division of Long Term Care
For technical assistance in completing the Work Plan Table and companion text, you may email:
[email protected].
40
Appendices
A
No Wrong Door/Single Entry Point
A.1 Description of the NWD/SEP System
A.2 List of Potential NWD/SEP Entities and Locations
A.2.a
CASA Association of New York State Member List (updated December 2012)
A.2.b
Nursing Home Transition and Diversion (NHTD) Waiver Program, Regional Resource
Development Center (RRDC) Contact List (effective January 4, 2013)
A.2.c
Home Care Services Program, Community Alternative Systems Agency (CASA), List of
Borough Offices (revised May 24, 2011)
A.2.d
OPWDD – Regional Front Door Access Numbers
A.2.e
Independent Living Centers
A.2.f
Local Department of Social Services List (LDSS)
A.2.g
New York Connects List (August 2013)
A.2.h
OMH Field Offices Field Offices
B
Core Standard Assessment/Core Data Set - Crosswalk
B.1 Crosswalk – DOH - Adult
B.2 Crosswalk – DOH – Children 0 - 3
B.3 Crosswalk – DOH – Children 4 - 17
B.4 Crosswalk – OPWDD
B.5 Crosswalk – OMH –CANS-NY
B.6 Crosswalk – OMH – CDS
C
Conflict Free Case Management (CFCM)
C.1 Strengths and weakness of existing case management system
D
Data Collection and Reporting
D.1 Protocol for Service Data
E
Sustainability
E.1 Description of funding source and Description of how State sill use the enhanced funding earned
through the program
F
Housing Options
F.1 Description of settings in which ID/DD population currently resides and Description of strategy
for building housing options for the ID/DD population
G
Acronym List
H
OPWDD Developmental Disabilities Transformation 11/30/2013 Deliverable
41
Appendix A.1: Description of the NWD/SEP System
A.1-1
STAGE 1 - TOUCHPOINTS FOR ENTRY AND LEVEL I SCREEN
INDIVIDUALS /CAREGIVERS
NY Connects Resource Directory
Website
www.nyconnects.ny.gov
(includes link to myBenefits.ny.gov)
NY Connects Network of
NWDs/SEPs
1-800 Number
Virtual Call Center - routes to
NY Connects Network
Phone, internet, face to face in office,
home or community
Explore addition
of automated
Level I SelfAssessment Screen
*See appendix A.2 for list of potential
NWDs/SEPs
LEVEL I SCREEN: Preliminary functional and financial assessment
conducted by NWD/SEP
Some individuals may not need a full Level I screen – only need
“light touch”
If appears not eligible for Medicaid, NWD provides I & A on array of
LTSS available and any other programs for which the person may be
eligible
If individual found potentially eligible for Medicaid, linked to Stage
2: Streamlined Eligibility & Enrollment Processes - agency eligibility
determination as required and Level II Assessment
A.1-2
STAGE 2: STREAMLINED ELIGIBILITY & ENROLLMENT PROCESS: Agency Eligibility Determination as Required and Level II Assessment
OPWDD has a required eligibility
/or that
determination process
determines if the individual proceeds
to the Level II Assessment
LEVEL II ASSESSMENT
Individual not Medicaid
eligible – returns to NY
Connects Network
Individual determined
financially Medicaid eligible
and functionally for community
LTSS
Enrolled in
Medicaid MLTC, MCO,
DISCO,
Behavioral
Health Plan,
Waiver, etc.
Stage 2 Streamlined Eligibility 1
A.1-3
Appendix A.2.a: List of Potential NWD/SEP Entities and Locations – CASA
Association of New York State Member List
A.2.a-1
CASA ASSOCIATION OF NEW YORK STATE
MEMBER LIST (Updated December 2012)
Albany
Albany
Allegany
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
CMM/DOH
2019 Corning Tower
Albany, NY 12210
Albany County DSS
162 Washington Avenue
Albany, NY 12214-7612
Allegany County OFA
17 Court Street
Belmont, NY 14813
BCOB
P. O. Box 1766
Binghamton, NY 13902
Cattaraugus County DSS
1701 Lincoln Avenue
Olean, NY 14760
LTC Access Office
149 Genesee Street
Boyle Center
Auburn, NY 13021
7 North Erie Street
Hall R. Clothier Building
Mayville, NY 14757
OFA Care Access & Resource
425 Pennsylvania Avenue
P. O. Box 588
Elmira, NY 14902-0588
Columbia County DSS
P. O. Box 458
Hudson, NY 12534
Cortland County DSS
Medical Services
60 Central Avenue
Cortland, NY 13045
Delaware County Office for LTC
111 Main Street
Delhi, NY 13754
Dutchess County CASA
27 High Street
Poughkeepsie, NY 12601
Statler Tower, Suite 1800
107 Delaware Avenue
Buffalo, NY 14202
DSS Coord. Care Unit
P. O. Box 217
Elizabethtown, NY 12932
Coord. Care Unit
Franklin Co. Court House
Malone, NY 12953
A.2.a-2
Franklin
Fulton
Greene
Herkimer
Monroe
Montgomery
Nassau
Niagara
NYC
NYC
Oneida
Onondaga
Orange
Orleans
Medicaid – DSS
355 W. Main Street
Suite 331
Malone, NY 12953
LTC Coordinator
Cent. Assess. & Place. Unit
P. O. Box 549
Johnstown, NY 12095
Greene Co. CAU Unit
P. O. Box 528
Catskill, NY 12414
301 N. Washington Street
Suite 2110
Herkimer, NY 13350-2906
111 Westfall Road
Room 804
Rochester, NY 14620
Montgomery County DSS
COB-Broadway
P. O. Box 745
Fonda, NY 12068
Nassau County DSS
101 County Seat Drive
Mineola, NY 11501-4821
Niagara County DSS
301 10th Street
PO Box 865
Niagara Falls, NY 14302-0865
Director LTHHCP
NYCHRA/HCSP
309 E 94th. Street
Room 506
New York, NY 10128
Human Resources Administration
Home Care Services Program
309 E. 94th Street, 4th Floor
New York, NY 10128
Office of Continuing Care
235 Elizabeth Street
Utica, NY 13502
5065 W. Seneca Turnpike
Syracuse, NY 13215
Case Supervisor
141 Broadway
Newburg, NY 12550
Office for the Aging
14016 Route 31, West
Albion, NY 14411
A.2.a-3
Otsego
Putnam
Rensselaer
Rockland
Saratoga
Schenectady
Seneca
St. Lawrence
Suffolk
Sullivan
Tioga
Tompkins
Ulster
Otsego County
Office for the Aging
197 Main Street
Cooperstown, NY 13326
Putnam Co. DSS LTC Unit
110 Old Route Six Center
Carmel, NY 10512
Dept of Social Services
133 Bloomingrove Drive
Troy, NY 12180
Home Care Coordinator
Rockland County DSS
Building C, Sanatorium Rd.
P. O. Box 307
Pomona, NY 10970
Saratoga County DSS
152 W. High Street
Ballston Spa, NY 12020
Dept. of Senior & LTC Services
107 Nott Terr, Suite 202
Schenectady, NY 12308
Seneca County DSS
One Dipronio Drive
P. O. Box 690
Waterloo, NY 13165
St. Lawrence Co. DSS
80 SH 310, Suite 7
Canton, NY 13617-1497
Director, Med. Svc. Bureau
P. O. Box 18100
Hauppauge, NY 1178-8900
Sullivan County
Department of Family Services
P. O. Box 231
Liberty, NY 12754
Tioga County DSS
1062 State Rte 38
PO Box 240
Owego, NY 13827
Tompkins County DSS
320 West State Street
Ithaca, NY 14850
Director of Public Health
Ulster Co. Health Dept.
300 Flatbush Avenue
P. O. Box 1800
Kingston, NY 12401-1800
A.2.a-4
Warren
Washington
Westchester
Westchester
Yates
CASA Coordinator
Warren Co. Municipal Center
Lake George, NY 12845
Washington County DSS
383 Broadway
Fort Edward, NY 12828
Office Med/Home Care Ser.
270 North Avenue
New Rochelle, NY 10801
Westchester Co. DSS
112 East Post Road
White Plains, NY 10601
Yates Co. Public Health
417 Liberty Street
Suite 2120
Penn Yann, NY 14527-1122
A.2.a-5
Appendix A.2.a: List of Potential NWD/SEP Entities and Locations – Nursing
Home Transition and Diversion (NHTD) Waiver Program, Regional Resource
Development Center (RRDC) Contact List
A.2.b-1
NEW YORK STATE DEPARTMENT OF HEALTH – DIVISION OF LONG TERM CARE
Nursing Home Transition and Diversion (NHTD) Waiver Program
Regional Resource Development Center (RRDC) Contact List
Effective: January 4, 2013
Region/County
Regional Resource Development
Center
Adirondack: Fulton,
Montgomery, Saratoga, W ashington, W arren,
Hamilton, Essex, Franklin and Clinton
Glens Falls Independent Living Center
d/b/a Southern Adirondack Independent Living (SAIL)
71 Glenwood Avenue Queensbury, NY
12804 www.sail-center.org
Binghamton/Southern Tier:
Broome, Steuben, Schuyler, Tioga, Delaware,
Tompkins, Cortland, Chenango, Cayuga, Chemung,
Allegany and Otsego
Southern Tier Independence Center (STIC) 135 East
Frederick Street
Binghamton, NY 13904
www.stic-cil.org
Buffalo: Erie, Chautauqua,
Cattaraugus, W yoming, Orleans and Niagara
Headway of W estern New York, Inc.
2635 Delaware Ave. Buffalo, NY 14216
www.headwayofwny.org
Capital: Albany, Schenectady,
Greene, Rensselaer, Schoharie and Columbia
Sunnyview Hospital and Rehabilitation
1270 Belmont Avenue Schenectady, NY
12308 www.sunnyview.org
Long Island: Nassau and
Suffolk
Self Initiated Living Options, Inc. (Suffolk
Independent Living Organization (SILO) 2111 Lakeland Ave.
Suite A Ronkonkoma, NY 11779 www.siloinc.org
A.2.b-2
Lower Hudson Valley:
Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster
and W estchester
W estchester Independent Living Center
200 Hamilton Avenue 2nd Floor W hite Plains, NY 10601
www.wilc.org
New York City:
New York, Kings, Richmond, Bronx, Queens
Visiting Nurse Association Health Care
Services
d.b.a. VNA of Staten Island 400 Lake Avenue
Staten Island, NY 10303
www.vnasi.org
Rochester: Monroe, W ayne,
Ontario, Seneca, Genesee, Livingston and Yates
Unity Health System NHTD W aiver
th
6 Floor
Unity Health – St. Mary’s Campus
89 Genesee Street Rochester, NY 14611
www.unityhealth.org
Syracuse: Onondaga, Madison, Herkimer, Oneida,
Oswego, Lewis, Jefferson and St. Lawrence
ARISE Child and Family Service, Inc. 635 James Street
Syracuse, NY 13203 www.ariseinc.org
A.2.b-3
Appendix A.2.c: List of Potential NWD/SEP Entities and Locations – Home Care
Services Program, Community Alternative Systems Agency (CASA), List of
Borough Offices
A.2.c-1
Brooklyn
Bronx
Home Care Services Program Community Alternative Systems Agency (CASA), List of Borough Offices
Bronx CASA
530 West 135th Street, 2nd Floor, New York, NY 10031 S Level
(Community Districts 1-12)
Phone: (718) 510-0106; 510-0153
Fax: (718) 508-0885
CASA VI
88 Third Avenue, Brooklyn, NY 11217
3rd Fl.
(Community Districts 1-4, 6-9, 14,15)
Phone: (718) 250-5631
Fax: (718) 250-5621
CASA VII
3050 West 21st Street, 2nd Floor
Brooklyn, NY 11224
Telephone #: 718-333-3108; 718-333-3109
CASA VIII
253 Schermerhorn Street, 3rd Fl., Brooklyn, NY 11201
(Community Districts 5, 16-18)
Staten
Island
Queens
Manhattan
Phone: Director (718) 722-3119; Intake (718) 722-3678
Fax:
(718) 923-6638/722-4644
CASA V
132 W.125th St., New York, NY 10027
5th Floor
(Community Districts 9-12)
Phone: (212) 665-3233
Fax: (212) 666-1459
CASA II
45-02 32nd Place, Long Island City, NY 11101
3rd Floor
(Community Districts 1-7, 11)
Phone: (718) 752-4455
Fax: (718) 752- 4348
CASA X
92-31 Union Hall St., Jamaica, NY 11433
4th Floor
(Community Districts 8-10, 12-14)
Phone: (718) 262-3514
Fax: (718) 262-3498
CASA IV
215 Bay St., Staten Island, NY 10301 (Community Districts 1-3)
Phone: (718) 556-7331
Fax: (718) 556-7315
A.2.c-2
Appendix A.2.d: List of Potential NWD/SEP Entities and Locations – OPWDD –
Regional Front Door Access Numbers
A.2.d-1
Region 1
Finger Lakes
(855)-OPWDDFL (679-3335) (Counties: Chemung, Livingston, Monroe, Ontario, Schuyler,
Seneca, Steuben, Wayne, Wyoming, Yates) operational 8/1/13
Western
(800) 487-6310 (Counties: Allegany, Cattaraugus, Chautauqua, Erie, Genesee,
Niagara, Orleans)
operational 8/1/13
Region 2
Broome
(607) 771-7784 press 0 (Counties: Broome, Chenango, Delaware, Otsego,
Tioga, Tompkins)
CNY
(315) 425-5322 (Counties: Cayuga, Cortland, Onondaga, Oswego)
(315) 793-9600 Ext. 603 (Counties: Herkimer, Lewis, Madison, Oneida)
Sunmount
(518) 561-8190 (Counties: Clinton, Essex, Franklin, Hamilton, Jefferson, St. Lawrence)
Region 3
Capital
518-370-7413 (Counties: Albany, Fulton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren,
Washington)
Hudson Valley
845-947-6011 Rockland
845-695-7330 Orange Sullivan
914-332-8960 Westchester
Taconic
845-473-5050 (Counties: Putnam, Dutchess County)
845-382-1899 (Counties: Columbia, Green, Ulster,)
Region 4
Queens
(718) 217-6485
Kings
(718) 642-8576
Manhattan
(212) 229-3132
A.2.d-2
Richmond
(718) 982-1913
Bronx
(718) 430-0757
Region 5
(631) 434-6000 (Counties: Nassau, Suffolk)
(631) 434-6100
Other Resources
Front Door Technical Support Email: [email protected]
A.2.d-3
Appendix A.2.e: List of Potential NWD/SEP Entities and Locations –
Independent Living Centers
A.2.e-1
Auburn Center: Options for Independence | www.optionsforindependence.org
Cayuga and Seneca counties
Binghamton Center: Southern Tier Independence Center | www.stic-cil.org
Broome, Chenango, and Tioga counties
Buffalo Center: Western New York Independent Living | www.wnyil.org
Bronx Center: Bronx Independent Living Services | www.bils.org
Brooklyn Center: Brooklyn Center for Independence of the Disabled | www.bcid.org
Brooklyn (Kings)
Corning Center: AIM Independent Living Center | www.aimcil.com
Cortland Center: Access to Independence of Cortland County | www.aticortland.org
Cortland
Harlem Center: Harlem Independent Living Center | www.hilc.org
Primarily Harlem, but serves other boroughs
Ithaca Center: The Finger Lakes Independence Center | www.fliconline.org
Kingston Center: Resource Center for Accessible Living | www.rcal.org
Levittown Center: Long Island Center for Independent Living | http://licil.net/wordpress/
Nassau
Manhattan Center: Center for Independence of the Disabled New York | www.cidny.org
New York City
Monticello: Action Toward Independence | www.atitoday.org/
Sullivan and Orange Counties
New City Center: Rockland Independent Living Center | www.rilc.org
Lower Hudson Valley community
Newburgh Center: Independent Living, Inc. | www.myindependentliving.org
Mid Hudson community
Olean Center: Directions in Independent Living | www.oleanilc.org
Allegany and Cattaraugus counties
Oneonta Center: Catskill Center for Independence | www.ccfi.us
Plattsburgh Center: North Country Center for Independence | www.ncci-online.com
Clinton and Essex counties
A.2.e-2
Poughkeepsie Center: Taconic Resources for Independence | www.taconicresources.org
Dutchess
Queensbury Center: Southern Adirondack Independent Living | www.sail-center.org
Primarily Warren, Washington, and Saratoga counties
Rochester Center: Center for Disability Rights | www.cdrnys.org
Rochester Center: Regional Center for Independent Living | www.rcil.org
Ronkonkoma: Suffolk Independent Living Organization | www.siloinc.org
Suffolk
Saranac Lake Center: Tri-Lakes Center for Independent Living | www.tlcil.org
Southern Franklin and Essex counties
Staten Island Center: Staten Island Center for Independent Living | www.siciliving.org
Staten Island (Richmond)
Syracuse Center: ARISE | www.ariseinc.org
Onondaga, Madison, Oswego counties
Troy Center: Independent Living Center of the Hudson Valley | www.ilchv.org
Hudson Valley region, including Albany, Rensselaer, Columbia counties
Utica Center: Resource Center for Independent Living | www.rcil.com
Central New York
Watertown Center: Northern Regional Center for Independent Living | www.nrcil.net
Jefferson and Lewis counties
White Plains Center: Westchester Independent Living Center | www.wilc.org
Westchester and Lower Hudson Valley region
Yonkers Center: Westchester Disabled on the Move | www.wdom.org
CASA
CASA: Advocates for Children of New York State
Penny Page, Executive Director
[email protected]
911 Central Avenue, #117
Albany, NY 12206
Phone: 518-426-5354
Toll Free: 877-80-VOICE
Fax: 518-426-5348
A.2.e-3
Appendix A.2.f: List of Potential NWD/SEP Entities and Locations - Local
Department of Social Services (LDSS) List
A.2.f-1
Albany
162 Washington Avenue Albany, NY 12210 · (518) 447-7300
Website: http://www.albanycounty.com/departments/dss/
Allegany
County Office Building ·7 Court St. · Belmont, NY 14813-1077 · (585) 268-9622
Website: http://www.alleganyco.com/default.asp?show=btn_ds
Broome
36-42 Main Street · Binghamton, NY 13905-3199 · (607) 778-8850
Website: http://www.gobroomecounty.com/dss/
Cattaraugus
One Leo Moss Drive · Suite 6010 · Olean, NY 14760-1158 · (716) 373-8065
Website: http://www.co.cattaraugus.ny.us/dss/
Cayuga
County Office Building · 160 Genesee Street · 2nd Floor · Auburn, NY 13021-3433 · (315) 253-1451
Website: http://co.cayuga.ny.us/hhs/index.html
Chautauqua
Hall R. Clothier Building · Mayville, NY 14757 · (716) 753-4421
Website: http://www.co.chautauqua.ny.us/departments/dss/Pages/default.aspx
Chemung
Human Resource Center · 425 Pennsylvania Avenue · P.O. Box 588 · Elmira, NY 14902-0588 · (607) 737-5309
Website: http://www.chemungcounty.com/index.asp?pageId=266
Chenango
5 Court Street and 14 West Park Place · Norwich, NY 13815 · (607) 337-1500
Website: http://ccdss.peppytech.com/
Clinton
13 Durkee Street · Plattsburgh, NY 12901-2911· (518) 565-3300
Website: http://www.clintoncountygov.com/Departments/DSS/index.htm
Columbia
25 Railroad Avenue · P.O. Box 458 · Hudson, NY 12534 · (518) 828-9411
Cortland
County Office Building· 60 Central Avenue · Cortland, NY 13045-5590 · (607) 753-5248
Website: http://www.cortland-co.org/dss/
Delaware
111 Main Street · P.O. Box 469 · Delhi, NY 13753-1265· (607) 832-5300
Website: http://www.co.delaware.ny.us/departments/dss/dss.htm
A.2.f-2
Dutchess
60 Market Street · Poughkeepsie, NY 12601-3299· (845) 486-3000
Website: http://www.co.dutchess.ny.us/CountyGov/Departments/SocialServices/SSIndex.htm
Erie
Rath County Office Building · 95 Franklin Street, 8th Floor · Buffalo, NY 14202-3959 · (716) 858-8000
Website: http://www.erie.gov/depts/socialservices/
Essex
7551 Court St.· PO Box 217 · Elizabethtown, NY 12932· (518) 873-3441
Franklin
355 West Main Street, Suite 331 · Malone, NY 12953· (518) 481-1808
Website: http://franklincony.org/content/
Fulton
4 Daisy Lane · P.O. Box 549 · Johnstown, NY 12095 · (518) 736-5640
Website: http://www.fultoncountyny.gov/index.php?word=departments/socialservices.htm
Genesee
5130 East Main Street · Suite #3 · Batavia, NY 14020-3497· (585) 344-2580
Website: http://www.co.genesee.ny.us/dpt/socialservices/index.html
Greene
411 Main Street · P.O. Box 528 · Catskill, NY 12414-1716 · (518) 719-3700 or Toll Free 1-877-794-9268
Website: http://www.greenegovernment.com/department/socialserv/
Hamilton
White Birch Lane · P.O. Box 725 · Indian Lake, NY 12842-0725 · (518) 648-6131
Website: http://www.hamiltoncounty.com/county-government/departments-services#SocialServicesDepartment
Herkimer
301 North Washington Street ·Suite 2110 · Herkimer, NY 13350 · (315) 867-1291
Website: http://herkimercounty.org/content/Departments/View/10
Jefferson
Human Services Building · 250 Arsenal Street · Watertown, NY 13601 · (315) 782-9030
Website: http://www.co.jefferson.ny.us/index.aspx?page=115
Lewis
5274 Outer Stowe Street · P.O. Box 193 · Lowville, NY 13367 · (315) 376-5400
Website: http://lewiscountyny.org/content/Departments/View/30?
Livingston
1 Murray Hill Drive · Mt. Morris, NY 14510-1699 · (585) 243-7300
Website: http://www.co.livingston.state.ny.us/dss.htm
A.2.f-3
Madison
Madison County Complex, Building 1 · 133 North Court Street · P.O. Box 637 · Wampsville, NY 13163 · (315)
366-2211
Website: http://www.madisoncounty.org/DSS2/index.html
Monroe
111 Westfall Road · Rochester, NY 14620-4686 · (585) 753-6298
Website: http://www.monroecounty.gov/hs-index.php
Montgomery
County Office Building · P.O. Box 745 · Fonda, NY 12068 · (518) 853-4646
Nassau
60 Charles Lindbergh Blvd · Uniondale, NY 11553-3656 · (516) 227-8519
Website: http://www.nassaucountyny.gov/agencies/dss/DSSHome.htm
New York City
180 Water St. 25th Fl. · New York, NY 10038 · Info-Line: (718)-557-1399 Outside NYC: (718) 557-1399
Website: http://www.nyc.gov/html/hra/html/home/home.shtml
NYC Administration for Children's Services · 150 William St. 18th Fl. · New York, NY 10038 · Dial 311 or
(212) 341-0900
Website: http://www.nyc.gov/acs
Niagara
20 East Avenue P.O. Box 506 · Lockport, NY 14095-0506 · (716) 439-7600
Website: http://www.niagaracounty.com/departments.asp?City=Social+Services
Oneida
County Office Building · 800 Park Avenue · Utica, NY 13501-2981· (315) 798-5700
Website: http://www.ocgov.net/oneida/socialservices
Onondaga
John H. Mulroy Civic Center, 12th Floor · 421 Montgomery Street · Syracuse, NY 13202-2923 · (315) 4352985
Website: http://www.ongov.net/dss/
Ontario
3010 County Complex Drive · Canandaigua, NY 14424-1296 · (585) 396-4060 or Toll Free (877) 814-6907
Website: http://www.co.ontario.ny.us/social_services/
Orange
11 Quarry Road, Box Z · Goshen, NY 10924-0678 · (845) 291-4000
Website: http://www.co.orange.ny.us/content/124/1374/default.aspx
Orleans
14016 Route 31 West · Albion, NY 14411-9365 · (585) 589-7000
Website:http://www.orleansny.com/Departments/ResidentServices/DepartmentofSocialServices/tabid/150/Defa
ult.aspx
A.2.f-4
Oswego
100 Spring Street · P.O. Box 1320 · Mexico, NY 13114 · (315) 963-5000
Website: http://www.co.oswego.ny.us/dss/
Otsego
County Office Building · 197 Main Street · Cooperstown, NY 13326-1196 · (607) 547-4355
Website: http://www.otsegocounty.com/depts/dss/
Putnam
110 Old Route 6 · Carmel, NY 10512-2110 · (845) 808-1500
Website: http://www.putnamcountyny.com/socialservices/
Rensselaer
127 Bloomingrove Drive · Troy, NY 12180-8403 · (518) 833-6000
Website: http://www.rensco.com/departments_socialservices.asp
Rockland
Robert L. Yeager Health Center, Building L · Sanatorium Road ·
Pomona, NY 10970 · 845-364-2020
Website: http://rocklandgov.com/departments/social-services/
Saint Lawrence
Harold B. Smith County Office Building · 6 Judson Street · Canton, NY 13617-1197 · (315) 379-2111
Website: http://www.co.st-lawrence.ny.us/Social_Services/SLCSS.htm
Saratoga
152 West High Street · Ballston Spa, NY 12020 · (518) 884-4140
Website: http://www.saratogacountyny.gov/departments.asp?did=150
Schenectady
797 Broadway; Schenectady, NY 12305 · (518) 388-4470
http://www.schenectadycounty.com/
Schoharie
County Office Building · P.O. Box 687 · Schoharie, NY 12157 · (518) 295-8334
Website: http://www.schohariecounty-ny.gov/CountyWebSite/index.jsp
Schuyler
323 Owego Street - Unit 3 · Montour Falls, NY 14865 · (607) 535-8303
Website: http://www.schuylercounty.us/dss.htm
Seneca
1 DiPronio Drive · P.O. Box 690 · Waterloo, NY 13165-0690 · (315) 539-1800
Website: http://www.co.seneca.ny.us/dpt-divhumserv-children-family.php
Steuben
3 East Pulteney Square · Bath, NY 14810 · (607) 776-7611
Website: http://www.steubencony.org/dss.html
A.2.f-5
Suffolk
Mary Gordon Building · 3085 Veterans Memorial Highway · Ronkonkoma, NY 11779 · (631) 854-9935
Website: http://www.co.suffolk.ny.us/departments/socialservices.aspx
Sullivan
16 Community Lane · P.O. Box 231 · Liberty, NY 12754 · (845) 292-0100
Website: http://www.co.sullivan.ny.us/Departments/HealthandFamilyServices/tabid/3120/Default.aspx
Tioga
1062 State Route 38 · P.O. Box 240 · Owego, NY 13827 · (607) 687-8300
Website: http://www.tiogacountyny.com/departments/social-services.html
Tompkins
Human Services Building · 320 West Martin Luther King Jr. / West State Street · Ithaca, NY. 14850 · (607)
274-5252
Website:http://www.tompkins-co.org/departments/detail.aspx?DeptID=41
Ulster
1061 Development Court · Kingston, NY 12401-1959 · (845) 334-5000
Website:http://www.co.ulster.ny.us/resources/socservices.html
Warren
Warren Co. Municipal Center · 1340 State Route 9 · Lake George, NY 12845-9803 · (518) 761-6327
Website: http://www.co.warren.ny.us/socserv/
Washington
Municipal Center, Building B · 383 Broadway · Fort Edward, NY 12828 · (518) 746-2300
Website:http://www.co.washington.ny.us/Departments/Dss/dss.htm
Wayne
77 Water Street · P.O. Box 10 · Lyons, NY 14489-0010 · (315) 946-4881
Website: http://www.co.wayne.ny.us/departments/dss/dss.htm
Westchester
10 County Center Road, 2nd Floor · White Plains, NY 10607· (914) 995-5477, (914) 995-6521, (914) 995-6522
Website:
http://socialservices.westchestergov.com/index.php?option=com_content&view=article&id=978&Itemid=3989
Wyoming
466 North Main Street · Warsaw, NY 14569-1080 · (716) 786-8900
Website: http://www.wyomingco.net/socialservices/main.html
Yates
County Office Building · 417 Liberty Street, Suite 2122 · Penn Yan, NY 14527-1118 · (315) 536-5183
Website: http://www.yatescounty.org/upload/12/dss/frameset.html
A.2.f-6
Appendix A.2.g: List of Potential NWD/SEP Entities and Locations – New York
Connects List
A.2.g-1
Albany
Allegany
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Albany County NY Connects
162 Washington Avenue
Albany, NY 12210
Allegany County NY Connects
6085 State Route 19 North
Belmont, NY 14813
Broome County CASA/NY Connects
60 Hawley Street
Binghamton, NY 13902
Cattaraugus County NY Connects
One Leo Moss Drive, Suite 7610
Olean, NY 14760
NY Connects Long Term Care Office
149 Genesee Street
Auburn, NY 13021
Chautauqua County NY Connects
7 North Erie Street
Mayville, NY 14757
Chemung County Department of Aging
& Long Term Care
425 Pennsylvania Avenue
Elmira, NY 14902
NY Connects Chenango
5 Court Street
Norwich, NY 13815
Clinton County Office for the Aging NY Connects
135 Margaret Street
Plattsburgh, NY 12901
NY Connects: Columbia County
325 Columbia Street
Hudson, NY 12534
Cortland County NY Connects
60 Central Avenue Room B6
Cortland, NY 13045
Delaware County NY Connects
6 Court Street
Delhi, NY 13753
NY Connects
27 High Street
Poughkeepsie, NY 12601
Erie County NY Connects
95 Franklin Street
Buffalo, NY 14202
Essex County NY Connects
132 Water Street
Elizabethtown, NY 12932
Franklin County NY Connects/C.A.R.E.S.
125 Catherine St
Malone, NY 12953
A.2.g-2
Fulton
Genesee
Greene
Herkimer
Jefferson
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
Niagara
Oneida
Onondaga
Ontario
Orange
Fulton County Office for Aging, NY Connects
19 North William Street
Johnstown, NY 12095
NY Connects Genesee Care Options
2 Bank Street
Batavia, NY 14020
Greene County OFA and NY Connects
411 Main Street
Catskill, NY 12414
NY Connects: Choices for Long Term Care in
Herkimer County
109 Mary Street
Herkimer, NY 13350
Jefferson County NY Connects
175 Arsenal Street
Watertown, NY 13601
NY Connects: Choices for Long Term Care
7550 S. State Street
Lowville, NY 13367
NY Connects Livingston County
3 Murray Hill Drive
Mt Morris, NY 14510
Madison County NY Connects
138 Dominick Bruno Blvd.
Canastota, NY 13032
Elder Source, NY Connects and Transportation
Access
1900 S. Clinton Ave.
Rochester, NY 14618
Montgomery County NY Connects
135 Guy Park Avenue
Amsterdam, NY 12010
Nassau County NY*Connects
60 Charles Lindbergh Blvd.
Uniondale, NY 11553
NY Connects Niagara County
111 Main Street
Lockport, NY 14094
NY Connects OFA/OCC
120 Airline Street Suite 201
Oriskany, NY 13424
Dept. of Aging & Youth NY Connects
421 Montgomery Street
Syracuse, NY 13202
Ontario County NY Connects
3010 County Complex Drive
Canandaigua, NY 14424
Orange County NY Connects
18 Seward Avenue
Middletown, NY 10940
A.2.g-3
Orleans
Otsego
Putnam
St. Lawrence
Saratoga
Schenectady
Schoharie
Schuyler
Steuben
Suffolk
Sullivan
Tioga
Tompkins
Ulster
Warren/Hamilton
Orleans NY Connects
14016 Route 31W
Albion, NY 14411
NY Connects of Otsego County
The Meadows Complex, Suite 5
140 County Highway 33W
Cooperstown, NY 13326
Putnam NY Connects
110 Old Route 6
Carmel, NY 10512
NY Connects: Choices for Long Term Care in
St. Lawrence County
80 State Highway 310
Canton, NY 13617
Saratoga County NY Connects
152 West High Street
Ballston Spa, NY 12020
Schenectady County NY Connects
107 Nott Terrace
Schenectady, NY 12308
Schoharie County NY Connects
113 Park Place, Suite 3
Schoharie, NY 12157
Schuyler County Office for the Aging/NY
Connects
323 Owego Street
Montour Falls, NY 14865
NY CONNECTS: Steuben County's Choices for
Long Term Care
3 East Pulteney Square
Bath, NY 14810
Suffolk NY Connects
100 Veterans Memorial Highway
Hauppauge, NY 11788
Sullivan NY CONNECTS
100 North Street
Monticello, NY 12701
Tioga NY Connects
9 Sheldon Guile Blvd
Owego, NY 13827
Tompkins County NY Connects
214 W. Martin Luther King Jr./State St.
Ithaca, NY 14850
Ulster County NY Connects
1003 Development Court
Kingston, NY 12401
Warren/Hamilton Counties Office for the Aging
NY Connects
1340 State Route 9
Lake George, NY 12845
A.2.g-4
Washington
Wayne
Westchester
Wyoming
Yates
St. Regis
Washington County Cares
383 Broadway
Fort Edward, NY 12828
Wayne County NY CONNECTS
1519 Nye Road, Suite 300
Lyons, NY 14489
NY Connects: Westchester Choices for
Long Term Care
9 South First Avenue, 10th floor
Mt. Vernon, NY 10550
Wyoming County NY Connects
8 Perry Avenue
Warsaw, NY 14569
Yates NY Connects
417 Liberty Street
Penn Yan, NY 14527
NY Connects
29 Business Park Road
Hogansburg, NY 13655
A.2.g-5
Appendix A.2.h: List of Potential NWD/SEP Entities and Locations – Office of
Mental Health Field Offices
A.2.h-1
Office of Mental Health (OMH)
Field Offices
OMH regions
Central New York Field Office
545 Cedar Street
Syracuse, NY 13210-2319
Phone: (315) 426-3930
Fax: (315) 426-3950
Counties in region: Broome, Cayuga, Chenango, Clinton, Cortland, Delaware, Essex, Fulton, Franklin,
Hamilton, Herkimer, Jefferson, Madison, Montgomery, Lewis, Oneida, Onondaga, Oswego, Otsego and St.
Lawrence
Hudson River Field Office
10 Ross Circle, Suite 5N
Poughkeepsie, NY 12601
Phone: (845) 454-8229
Fax: (845) 454-8218
Counties in region: Albany, Columbia, Dutchess, Greene, Orange, Putnam, Rensselaer, Rockland, Saratoga,
Schenectady, Schoharie, Sullivan, Ulster, Warren, Washington and Westchester
Long Island Field Office
Pilgrim PC, Building 45-3
998 Crooked Hill Road
West Brentwood, NY 11717-1087
Phone: (631) 761-2886
Fax: (631) 761-2820
Counties in region: Nassau and Suffolk
New York City Field Office
330 Fifth Avenue – 9th Floor
New York, NY 10001-3101
Phone: (212) 330-1650
Fax: (212) 330-6359
Counties in region: Bronx, Kings, New York, Queens and Richmond
A.2.h-2
Western New York Field Office
737 Delaware Ave, Suite 200
Buffalo, NY 14209
Phone: (716) 885-4219
Fax: (716) 885-4096
Counties in region: Allegany, Cattaraugus, Chautauqua, Chemung, Erie, Genesee, Livingston, Monroe, Niagara,
Ontario, Orleans, Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne, Wyoming, and Yates
A.2.h-3
Appendix B.1: Crosswalk – DOH – Adult
H-1
Balancing Incentive Program - Core Dataset Crosswalk
1. Please provide the following information:
CSA Contact:
Karen M. Ambros
Agency:
Department of Health, Office of Health Insurance Programs, Division of Long Term Care
Address:
Room 1913 Corning Tower
Address 2:
Empire State Plaza
City:
Albany
State:
NY
Zip:
12237
E-mail:
[email protected]
Phone:
518-473-6596
2. Pick a Population - Select the population(s) for which THIS Core Dataset Crosswalk applies.
*Please Note: The Core Dataset (CDS) must be collected for the following populations: developmental disability,
mental health, aging, and physical disability (across age groups). Other populations (e.g., Alzheimer’s, TBI) are
optional.
If you currently use (or intend to use) a single instrument to assess multiple populations, you should complete this
crosswalk once for all of those populations (e.g., aging and physical disability). In other words, you should complete
one instance of this crosswalk for every population or combination of populations that you assess (or plan to assess)
using the same set of questions.
Children
Adults
Developmental Disabilities
c
d
e
f
g
c
d
e
f
g
Mental Health
c
d
e
f
g
c
d
e
f
g
Physical Disabilities
c
d
e
f
g
Aging
c
d
e
f
g
Alzheimer's Disease
c
d
e
f
g
Traumatic Brain Injury
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Other (please specify)
Page 1
Domain: Activities of Daily Living
Topic: Eating
3. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Self-Performance: Eating
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 2: Questions
Nutritional Intake: Mode of Nutritional Intake
Assessment Tool 3: Name
interRAI Community Health Assessment (FS)/UAS-NY Community Assessment
Assessment Tool 3: Questions
Dental or Oral Issues
4. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
5. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112 "Comments" regarding eligibility determinations.
6
6. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
See #112. Overall Comments regarding a summative view.
5
See #112. Overall Comments” regarding supports-based, not deficit based language.
6
Page 2
Domain: Activities of Daily Living
Topic: Bathing
7. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance: Bathing
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
8. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
9. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
10. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 3
Domain: Activities of Daily Living
Topic: Dressing
11. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance: Dressing Upper Body
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 2: Questions
ADL Performance: Dressing Lower Body
Assessment Tool 3: Name
Assessment Tool 3: Questions
12. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
13. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
14. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 4
Domain: Activities of Daily Living
Topic: Hygiene
15. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Self Performance: Personal Hygiene (managing)
Assessment Tool 2: Name
interRAI Community Health Assessment (MHS)/UAS-NY Community Assessment
Assessment Tool 2: Questions
Mental State Indicators: Hygiene (poor)
Assessment Tool 3: Name
Assessment Tool 3: Questions
16. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
17. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
18. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 5
Domain: Activities of Daily Living
Topic: Toileting
19. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Self-Performance: Toilet Use
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 2: Questions
Continence: Bowel Continence
Assessment Tool 3: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 3: Questions
Continence: Bladder Continence
20. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Assessment Tool #2
Assessment Tool #3
Note here if this topic is not used for eligibility determination.
21. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
22. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 6
Domain: Activities of Daily Living
Topic: Mobility
23. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Self-Performance: Walking
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessmen
Assessment Tool 2: Questions
ADL Self-Performance: Locomotion
Assessment Tool 3: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 3: Questions
ADL: Primary Mode of Locomotion/Walking
24. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
25. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
26. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 7
Domain: Activities of Daily Living
Topic: Positioning
27. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Self-Performance: Bed Mobility
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
28. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
29. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
30. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 8
Domain: Activities of Daily Living
Topic: Transferring
31. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Self-Performance: Transfer Toilet
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
32. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
33. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
34. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 9
Domain: Activities of Daily Living
Topic: Communicating
35. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
Communication & Vision: Making Self Understood
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 2: Questions
Communication & Vision: Ability to Understand Others
Assessment Tool 3: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 3: Questions
Communication & Vision: Hearing/Vision
36. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
37. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
38. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 10
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Preparing Meals
39. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADL Performance & Capacity: Meal Preparation
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
40. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
41. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
42. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 11
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Shopping
43. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADL Performance & Capacity: Shopping
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
44. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
45. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
46. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 12
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Transportation
47. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADL Performance & Capacity: Transportation (how)
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 2: Questions
Functional Status: Driving
Assessment Tool 3: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 3: Questions
Functional Status: Tolerate Transportation
48. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
49. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
50. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 13
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Housework
51. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADL Performance & Capacity: Ordinary Housework
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
52. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
53. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
54. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 14
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Money
55. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADL Performance & Capacity: Managing Finances
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
56. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
57. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
58. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 15
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Telephone Use
59. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADL Performance & Capacity: Phone Use
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
60. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
61. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
62. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 16
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Medications
63. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADL Performance & Capacity: Managing Medications
Assessment Tool 2: Name
interRAI Community Health Assessment (FS)/UAS-NY Community Assessment
Assessment Tool 2: Questions
Medications: Adherent with Meds prescribed by a physician
Assessment Tool 3: Name
interRAI Community Health Assessment (MHS)/UAS-NY Community Assessment
Assessment Tool 3: Questions
Medications: Stopped taking psychotropics in last 90 days because of side effects
64. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
65. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
Also require the medications code table for a list of medications.
6
66. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 17
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Employment
67. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 1: Questions
Intake: Employment Status
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 2: Questions
Intake: Employment arrangements (exclude volunteering)
Assessment Tool 3: Name
Assessment Tool 3: Questions
68. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
69. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
70. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 18
Domain: Medical Conditions/Diagnoses
71. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment & FS/UAS-NY Community Assessment
Assessment Tool 1: Questions
Health Conditions: Musculoskeletal, Cardiac/Pulmonary, Psychiatric, Infections, Others
Assessment Tool 2: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 2: Questions
Health Conditions: Falls
Assessment Tool 3: Name
interRAI Community Health Assessment/UAS-NY Community Assessment
Assessment Tool 3: Questions
Health Conditions: Pain Symptoms & Control
72. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
73. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
Also require the diagnoses code table for a list of diagnoses.
6
74. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 19
Domain: Cognitive Function & Memory/Learning
Topic: Cognitive Function
75. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 1: Questions
Cognition: Cognitive Skills for Daily Decision Making
Assessment Tool 2: Name
interRAI Community Health Assessment & FS/UAS-NY Community Assessment
Assessment Tool 2: Questions
Cognition: Memory Recall Ability (short term and procedural)
Assessment Tool 3: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 3: Questions
Cognition: Change in Decision Making as compared to 90 Days ago
76. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
77. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
78. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 20
Domain: Cognitive Function & Memory/Learning
Topic: Judgment/Decision-Making
79. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment (FS) /UAS-NY Community Assessment
Assessment Tool 1: Questions
Cognition: Periodic Disordered Thinking or Awareness
Assessment Tool 2: Name
interRAI Community Health Assessment (FS) /UAS-NY Community Assessment
Assessment Tool 2: Questions
Cognition: Acute Change in Mental Status
Assessment Tool 3: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 3: Questions
Cognition: Change in Decision Making as Compared to 90 Days Ago
80. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
81. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
82. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 21
Domain: Cognitive Function & Memory/Learning
Topic: Memory/Learning
83. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment (FS)/UAS-NY Community Assessment
Assessment Tool 1: Questions
Cognition: Memory Recall Ability (short term/procedural/situational)
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
84. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
85. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
86. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 22
Domain: Behavior Concerns
Topic: Injurious Behavior
87. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment (MHS)/UAS-NY Community Assessment
Assessment Tool 1: Questions
Harm to self/others: Self-Injurious (biting, scratching, head banging, slapping, etc.)
Assessment Tool 2: Name
interRAI Community Health Assessment (MHS)/UAS-NY Community Assessment
Assessment Tool 2: Questions
Harm to self/others: Violence
Assessment Tool 3: Name
interRAI Community Health Assessment (MHS)/UAS-NY Community Assessment
Assessment Tool 3: Questions
Harm to self/others: Police Intervention
88. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
89. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
90. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 23
Domain: Behavior Concerns
Topic: Destructive Behavior
91. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment (MHS)/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Physical Abuse
Assessment Tool 2: Name
interRAI Community Health Assessment (MHS)/UAS-NY Community Assessment
Assessment Tool 2: Questions
Behavior Symptoms: Verbal Abuse
Assessment Tool 3: Name
Assessment Tool 3: Questions
92. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
93. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
94. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 24
Domain: Behavior Concerns
Topic: Socially Offensive Behaviors
95. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Socially Inappropriate or Disruptive Behavior
Assessment Tool 2: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 2: Questions
Behavior Symptoms: Inappropriate Public Sexual Behavior or Disrobing
Assessment Tool 3: Name
Assessment Tool 3: Questions
96. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
97. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
98. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 25
Domain: Behavior Concerns
Topic: Uncooperative Behavior
99. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Resists Care
Assessment Tool 2: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 2: Questions
Mood & Behavior: Negative Statements
Assessment Tool 3: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 3: Questions
Mood & Behavior: Persistent Anger
100. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
101. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
102. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 26
Domain: Behavior Concerns
Topic: Other Serious Behavior
103. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Wandering
Assessment Tool 2: Name
interRAI Community Health Assessment (FS) /UAS-NY Community Assessment
Assessment Tool 2: Questions
Mood & Behavior: Recurrent statements- terrible to happen
Assessment Tool 3: Name
interRAI Community Health Assessment (FS) /UAS-NY Community Assessment
Assessment Tool 3: Questions
Mood & Behavior: Anhedonia
104. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
105. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
106. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 27
Additional Topics (optional)
107. Topic:
Instrumental Activities of Daily Living
108. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 1: Questions
Stairs- how a full flight of stairs is managed.
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
109. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
110. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
111. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 28
Comments
Please use this page to provide any additional information.
112. Comments
The templates include items marked for “eligibility determination” defined as nursing home level of
care only, which is a part of programmatic eligibility. Programmatic eligibility determinations defined
by statute and regulations involve many more items (and rule out logic) than are included in these
domains. To list all these items and logic entails describing the inner workings of the assessment
system, which seems outside of the scope and construct of the templates.
5
While the items in the topic represent the key items for that topic, the assessment instrument
contains more items for many of the topics. It would be difficult to say whether the items listed
provide a summative view without statistical review. Also, the assessment system produces
outcomes such as clinical access protocols, scales and resource utilization groups that require
domains, topics and items that are not addressed in the template.
The assessment instruments use empirical language designed to assess needs in a way which can
be validated. The items themselves include those which address strengths such as informal
supports and individual goals, for example. The assessment process involves more than Q&A; it
involves observation, discussion with the individual, family and/or review of documentation. The
selection options for many items begin with “independence” (described in terms of strengths) with 6
or more gradations. The outcomes include opportunities for improvement or prevention in addition
to the risk of decline and care needs.
6
113. More Comments
5
6
Page 29
Appendix B.2: Crosswalk –DOH – Children 0-3
B.2-1
Balancing Incentive Program - Core Dataset Crosswalk
1. Please provide the following information:
CSA Contact:
Karen M. Ambros
Agency:
Department of Health, Office of Health Insurance Programs, Division of Long Term Care
Address:
Room 1913 Corning Tower
Address 2:
Empire State Plaza
City:
Albany
State:
NY
Zip:
12237
E-mail:
[email protected]
Phone:
518-473-6596
2. Pick a Population - Select the population(s) for which THIS Core Dataset Crosswalk applies.
*Please Note: The Core Dataset (CDS) must be collected for the following populations: developmental disability,
mental health, aging, and physical disability (across age groups). Other populations (e.g., Alzheimer’s, TBI) are
optional.
If you currently use (or intend to use) a single instrument to assess multiple populations, you should complete this
crosswalk once for all of those populations (e.g., aging and physical disability). In other words, you should complete
one instance of this crosswalk for every population or combination of populations that you assess (or plan to assess)
using the same set of questions.
Children
Adults
Developmental Disabilities
c
d
e
f
g
c
d
e
f
g
Mental Health
c
d
e
f
g
c
d
e
f
g
Physical Disabilities
c
d
e
f
g
✔
c
d
e
f
g
Aging
c
d
e
f
g
c
d
e
f
g
Alzheimer's Disease
c
d
e
f
g
c
d
e
f
g
Traumatic Brain Injury
c
d
e
f
g
c
d
e
f
g
Other (please specify)
Page 1
Domain: Activities of Daily Living
Topic: Eating
3. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Eating
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
Oral & Nutritional Status: Mode of Nutritional Intake (last 3 days)
Assessment Tool 3: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 3: Questions
Oral & Nutritional Status: Dental
4. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
5. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112 "Comments" regarding eligibility determinations.
6
6. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
See #112. Overall Comments regarding a summative view.
5
See #112. Overall Comments” regarding supports-based, not deficit based language.
6
Page 2
Domain: Activities of Daily Living
Topic: Bathing
7. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Bathing
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
8. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
9. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
10. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 3
Domain: Activities of Daily Living
Topic: Dressing
11. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Dressing
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
12. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
13. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
14. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 4
Domain: Activities of Daily Living
Topic: Hygiene
15. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Personal Hygiene
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
16. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
17. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
18. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 5
Domain: Activities of Daily Living
Topic: Toileting
19. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Toilet Use
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
Special bowel/bladder appliance needed
Assessment Tool 3: Name
Assessment Tool 3: Questions
20. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
21. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
22. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 6
Domain: Activities of Daily Living
Topic: Mobility
23. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Locomotion/mobility inside the home
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
Wheelchair/cart/mobility device is main mode of locomotion
Assessment Tool 3: Name
Assessment Tool 3: Questions
24. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
25. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
26. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 7
Domain: Activities of Daily Living
Topic: Positioning
27. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Bed Mobility
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
ADLS Effect: Positioning
Assessment Tool 3: Name
Assessment Tool 3: Questions
28. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
29. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
30. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 8
Domain: Activities of Daily Living
Topic: Transferring
31. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADLS Effect: Transfers
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
32. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
33. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
34. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 9
Domain: Activities of Daily Living
Topic: Communicating
35. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Communication & Vision: Making Self Understood
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
Communication & Vision: Ability to Understand Others
Assessment Tool 3: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 3: Questions
Communication & Vision: Hearing/Vision
36. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
37. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
38. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 10
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Preparing Meals
39. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Effect: Meal Preparation
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
40. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
41. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
42. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 11
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Shopping
43. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Effect: Shopping
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
44. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
45. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
46. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 12
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Transportation
47. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Functional Status: Transportation (tolerate)
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
IADLS Effect: Escort to health care appointments
Assessment Tool 3: Name
Assessment Tool 3: Questions
48. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
49. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
50. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 13
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Housework
51. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Effect: Ordinary Housework
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
52. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
53. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
54. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 14
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Money
55. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
56. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used.
57. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
58. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 15
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Telephone Use
59. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
60. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used.
61. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
62. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 16
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Medications
63. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Effect: Managing Medications
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
Med & Allergies: Infant/toddler requires either prescription or over the counter medication
Assessment Tool 3: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 3: Questions
Med & Allergies: Parent/Caregiver Adherent with Medications Prescribed by Physician
64. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
65. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
Also require the medications code table for a list of medications.
6
66. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 17
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Employment
67. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
68. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used.
69. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
70. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 18
Domain: Medical Conditions/Diagnoses
71. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Health Conditions: Musculoskeletal, Cardiac/Pulmonary, Psychiatric, Infections, Others
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
Health Conditions: Pain Symptoms & Control
Assessment Tool 3: Name
Assessment Tool 3: Questions
72. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
73. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
Also require the diagnoses code table for a list of diagnoses.
6
74. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 19
Domain: Cognitive Function & Memory/Learning
Topic: Cognitive Function
75. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Cognition: Concerns About Development (voiced by caregivers or health professionals)
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
76. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
77. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
78. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 20
Domain: Cognitive Function & Memory/Learning
Topic: Judgment/Decision-Making
79. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
80. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used. Cannot be assessed in 0-3 age group.
81. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
82. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 21
Domain: Cognitive Function & Memory/Learning
Topic: Memory/Learning
83. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
84. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used. Cannot be assessed in the 0-3 age group.
85. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
86. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 22
Domain: Behavior Concerns
Topic: Injurious Behavior
87. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: injury to self
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
88. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
89. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
90. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 23
Domain: Behavior Concerns
Topic: Destructive Behavior
91. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Disruptive behavior
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
92. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
93. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
94. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 24
Domain: Behavior Concerns
Topic: Socially Offensive Behaviors
95. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
96. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used. Cannot be assessed in the 0-3 age group.
97. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
98. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 25
Domain: Behavior Concerns
Topic: Uncooperative Behavior
99. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Resists Care
Assessment Tool 2: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 2: Questions
Mood & Behavior: Persistent anger/irritability with self or others
Assessment Tool 3: Name
Assessment Tool 3: Questions
100. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
101. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
102. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 26
Domain: Behavior Concerns
Topic: Other Serious Behavior
103. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 0-3/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Repetitive behavior interferes with normal activities
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
104. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
105. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
106. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 27
Additional Topics (optional)
107. Topic:
108. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
109. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
110. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
111. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 28
Comments
Please use this page to provide any additional information.
112. Comments
The templates include items marked for “eligibility determination” defined as nursing home level of
care only, which is a part of programmatic eligibility. Programmatic eligibility determinations defined
by statute and regulations involve many more items (and rule out logic) than are included in these
domains. To list all these items and logic entails describing the inner workings of the assessment
system, which seems outside of the scope and construct of the templates.
5
While the items in the topic represent the key items for that topic, the assessment instrument
contains more items for many of the topics. It would be difficult to say whether the items listed
provide a summative view without a statistical review. Also, the assessment system produces
outcomes such as clinical access protocols, scales and resource utilization groups that require
domains, topics and items that are not addressed in the template.
The assessment instruments use empirical language designed to assess needs in a way which can
be validated. The items themselves include those which address strengths such as informal
supports and individual goals, for example. The assessment process involves more than Q&A; it
involves observation, discussion with the individual, family and/or review of documentation. The
selection options for many items begin with “independence” (described in terms of strengths) with 6
or more gradations. The outcomes include opportunities for improvement or prevention in addition
to the risk of decline and care needs.
6
113. More Comments
5
6
Page 29
Appendix B.3: Crosswalk –DOH – Children 4-7
B.3-1
Balancing Incentive Program - Core Dataset Crosswalk
1. Please provide the following information:
CSA Contact:
Karen M. Ambros
Agency:
Department of Health, Office of Health Insurance Programs, Division of Long Term Care
Address:
Room 1913 Corning Tower
Address 2:
Empire State Plaza
City:
Albany
State:
NY
Zip:
12237
E-mail:
[email protected]
Phone:
518-473-6596
2. Pick a Population - Select the population(s) for which THIS Core Dataset Crosswalk applies.
*Please Note: The Core Dataset (CDS) must be collected for the following populations: developmental disability,
mental health, aging, and physical disability (across age groups). Other populations (e.g., Alzheimer’s, TBI) are
optional.
If you currently use (or intend to use) a single instrument to assess multiple populations, you should complete this
crosswalk once for all of those populations (e.g., aging and physical disability). In other words, you should complete
one instance of this crosswalk for every population or combination of populations that you assess (or plan to assess)
using the same set of questions.
Children
Adults
Developmental Disabilities
c
d
e
f
g
c
d
e
f
g
Mental Health
c
d
e
f
g
c
d
e
f
g
Physical Disabilities
c
d
e
f
g
✔
c
d
e
f
g
Aging
c
d
e
f
g
c
d
e
f
g
Alzheimer's Disease
c
d
e
f
g
c
d
e
f
g
Traumatic Brain Injury
c
d
e
f
g
c
d
e
f
g
Other (please specify)
Page 1
Domain: Activities of Daily Living
Topic: Eating
3. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Eating
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Oral & Nutritional Status: Mode of Nutritional Intake (last 3 days)
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Oral & Nutritional Status: Dental or Oral
4. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
5. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112 "Comments" regarding eligibility determinations.
6
6. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
See #112. Overall Comments regarding a summative view.
5
See #112. Overall Comments” regarding supports-based, not deficit based language.
6
Page 2
Domain: Activities of Daily Living
Topic: Bathing
7. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
iinterRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Bathing
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
8. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
9. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
10. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 3
Domain: Activities of Daily Living
Topic: Dressing
11. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Dressing Upper Body
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
ADL Performance & Effect: Dressing Lower Body
Assessment Tool 3: Name
Assessment Tool 3: Questions
12. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
13. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
14. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 4
Domain: Activities of Daily Living
Topic: Hygiene
15. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Personal Hygiene
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
16. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
17. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
18. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 5
Domain: Activities of Daily Living
Topic: Toileting
19. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Toilet Use
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Continence: Bowel Continence
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Continence: Bladder Continence
20. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Assessment Tool #2
Assessment Tool #3
Note here if this topic is not used for eligibility determination.
21. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
22. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 6
Domain: Activities of Daily Living
Topic: Mobility
23. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Walking
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
ADL Performance & Effect: Locomotion
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
ADL Performance & Effect: Primary Mode of Locomotion Indoors
24. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
25. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
26. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 7
Domain: Activities of Daily Living
Topic: Positioning
27. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Bed Mobility
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
ADL Performance & Effect: Positioning
Assessment Tool 3: Name
Assessment Tool 3: Questions
28. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
29. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
30. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 8
Domain: Activities of Daily Living
Topic: Transferring
31. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
ADL Performance & Effect: Transfer Toilet
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
ADL Performance & Effect: Transfers
Assessment Tool 3: Name
Assessment Tool 3: Questions
32. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
33. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
34. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 9
Domain: Activities of Daily Living
Topic: Communicating
35. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Communication & Vision: Making Self Understood
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Communication & Vision: Ability to Understand Others
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Communication & Vision: Hearing/Vision
36. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
37. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
38. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 10
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Preparing Meals
39. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Performance & Effect: Meal Preparation
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
40. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
41. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
42. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 11
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Shopping
43. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Performance & Effect: Shopping
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
44. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
45. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
46. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 12
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Transportation
47. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Performance & Effect: Transportation (how)
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Functional Status: Transportation (tolerate)
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
IADLS Performance & Effect: Escort to health care appointments
48. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
49. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
50. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 13
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Housework
51. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Performance & Effect: Ordinary Housework
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
52. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
53. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
54. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 14
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Money
55. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Performance & Effect: Managing Money
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
56. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
57. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
58. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 15
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Telephone Use
59. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Performance & Effect: Phone Use
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
60. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
61. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
62. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 16
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Medications
63. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
IADLS Performance & Effect: Managing Medications
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Medications: Adherent with Medications prescribed by physician
Assessment Tool 3: Name
Assessment Tool 3: Questions
64. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
65. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
Also require the medications code table for a list of medications.
6
66. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 17
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Employment
67. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
68. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used.
69. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
70. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 18
Domain: Medical Conditions/Diagnoses
71. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Health Conditions: Musculoskeletal, Cardiac/Pulmonary, Psychiatric, Infections, Others
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Health Conditions: Pain Symptoms & Control
Assessment Tool 3: Name
Assessment Tool 3: Questions
72. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
73. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
Also require the diagnoses code table for a list of diagnoses.
6
74. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 19
Domain: Cognitive Function & Memory/Learning
Topic: Cognitive Function
75. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Cognition: Cognitive Skills for Daily Decision Making
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Cognition: Memory/Recall Ability (short-term/procedural/situational)
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Cognition: Change in Decision Making as compared to 90 Days ago
76. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
77. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
78. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 20
Domain: Cognitive Function & Memory/Learning
Topic: Judgment/Decision-Making
79. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Cognition: Periodic Disordered Thinking or Awareness
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Cognition: Acute Change in Mental Status from Child/Youth's Usual Functioning
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Cognition: Change in Decision Making as Compared to 90 Days Ago
80. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
81. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
82. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 21
Domain: Cognitive Function & Memory/Learning
Topic: Memory/Learning
83. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Cognition: Memory/Recall Ability (short-term/procedural/situational)
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
84. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
85. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
86. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 22
Domain: Behavior Concerns
Topic: Injurious Behavior
87. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Mood & Behavior: Self-injurious Ideation or Attempt
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Mood & Behavior: Intent of Any Self-injurious Attempt was to kill him/herself
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Behavior Symptoms: Injury to self
88. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
89. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
90. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 23
Domain: Behavior Concerns
Topic: Destructive Behavior
91. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Physical Abuse
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Behavior Symptoms: Verbal Abuse
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Behavior Symptoms: Bullying/menacing behavior
92. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #1
Note here if this topic is not used for eligibility determination.
93. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
94. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 24
Domain: Behavior Concerns
Topic: Socially Offensive Behaviors
95. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Socially Inappropriate or Disruptive Behavior
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Behavior Symptoms: Inappropriate Public Sexual Behavior or Disrobing
Assessment Tool 3: Name
Assessment Tool 3: Questions
96. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
97. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
98. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 25
Domain: Behavior Concerns
Topic: Uncooperative Behavior
99. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Resists Care
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Behavior Symptoms: Outburst of anger
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Mood & Behavior: Made negative statements
100. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
101. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
102. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 26
Domain: Behavior Concerns
Topic: Other Serious Behavior
103. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Behavior Symptoms: Wandering
Assessment Tool 2: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 2: Questions
Mood & Behavior: Repetitive behavior that interferes with normal activities
Assessment Tool 3: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 3: Questions
Mood & Behavior: Elopement
104. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
105. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
106. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 27
Additional Topics (optional)
107. Topic:
Instrumental Activities of Daily Living
108. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Pediatric 4-17/UAS-NY Community Assessment
Assessment Tool 1: Questions
Stairs- how a full flight of stairs is managed.
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
109. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
110. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
111. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 28
Comments
Please use this page to provide any additional information.
112. Comments
The templates include items marked for “eligibility determination” defined as nursing home level of
care only, which is a part of programmatic eligibility. Programmatic eligibility determinations defined
by statute and regulations involve many more items (and rule out logic) than are included in these
domains. To list all these items and logic entails describing the inner workings of the assessment
system, which seems outside of the scope and construct of the templates.
5
While the items in the topic represent the key items for that topic, the assessment instrument
contains more items for many of the topics. It would be difficult to say whether the items listed
provide a summative view without statistical studies. Also, the assessment system produces
outcomes such as clinical access protocols, scales and resource utilization groups that require
domains, topics and items that are not addressed in the template.
The assessment instruments use empirical language designed to assess needs in a way which can
be validated. The items themselves include those which address strengths such as informal
supports and individual goals, for example. The assessment process involves more than Q&A; it
involves observation, discussion with the individual, family and/or review of documentation. The
selection options for many items begin with “independence” (described in terms of strengths) with 6
or more gradations. The outcomes include opportunities for improvement or prevention in addition
to the risk of decline and care needs.
6
113. More Comments
5
6
Page 29
Balancing Incentive Program ­ Core Dataset Crosswalk
1. Please provide the following information: CSA Contact:
Diane Woodward
Agency:
New York State Office For People With Developmental Disabilities
Address:
44 Holland Avenue, 4th Floor
Address 2:
City:
Albany
State:
NY
Zip:
12229
E­mail:
[email protected]
Phone:
518-486-4260
2. Pick a Population ­ Select the population(s) for which THIS Core Dataset Crosswalk applies. *Please Note: The Core Dataset (CDS) must be collected for the following populations: developmental disability, mental health, aging, and physical disability (across age groups). Other populations (e.g., Alzheimer’s, TBI) are optional. If you currently use (or intend to use) a single instrument to assess multiple populations, you should complete this crosswalk once for all of those populations (e.g., aging and physical disability). In other words, you should complete one instance of this crosswalk for every population or combination of populations that you assess (or plan to assess) using the same set of questions. Children
Adults
Developmental Disabilities
c
d
e
f
g
✔
c
d
e
f
g
✔
Mental Health
c
d
e
f
g
c
d
e
f
g
Physical Disabilities
c
d
e
f
g
c
d
e
f
g
Aging
c
d
e
f
g
c
d
e
f
g
Alzheimer's Disease
c
d
e
f
g
c
d
e
f
g
Traumatic Brain Injury
c
d
e
f
g
c
d
e
f
g
Other (please specify) Page 1
Domain: Activities of Daily Living
Topic: Eating
3. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Eating
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Oral and Nutritional Status: Mode of Nutritional Intake
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Oral and Nutritional Status: Dental or Oral Issues
4. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic not used for eligibility determination.
5. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
See #122. Overall comments
6
6. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) See #112. Overall Comments regarding summative view.
See #112. Overall Comments regarding supports-based, not deficit based language.
5
6
Page 2
Domain: Activities of Daily Living
Topic: Bathing
7. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Bathing
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
8. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
9. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
10. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 3
Domain: Activities of Daily Living
Topic: Dressing
11. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Dressing Upper Body
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Self-Care Skills (ADL) Performance: Dressing Lower Body
Assessment Tool 3: Name
Assessment Tool 3: Questions
12. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
13. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
14. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 4
Domain: Activities of Daily Living
Topic: Hygiene
15. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Personal Hygiene (managing)
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Hygiene (poor)
Assessment Tool 3: Name
Assessment Tool 3: Questions
16. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. Topic is not used for eligibility determination.
17. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
18. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 5
Domain: Activities of Daily Living
Topic: Toileting
19. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Toilet Use
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Health Conditions: Bowel Continence
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Health Conditions: Bladder Continence
20. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
21. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
22. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 6
Domain: Activities of Daily Living
Topic: Mobility
23. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Walking
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Self-Care Skills (ADL) Performance: Locomotion
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Self-Care Skills (ADL) Performance: Primary Mode of Locomotion/Walking
24. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
25. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
26. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 7
Domain: Activities of Daily Living
Topic: Positioning
27. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Bed Mobility
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
28. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
29. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
30. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 8
Domain: Activities of Daily Living
Topic: Transferring
31. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Transfer Toilet
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
32. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
33. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
34. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 9
Domain: Activities of Daily Living
Topic: Communicating
35. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Communication & Vision: Making Self Understood
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Communication & Vision: Ability to Understand Others
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Communication & Vision: Communication Modes Used Daily
36. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
37. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
38. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 10
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Preparing Meals
39. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Meal Preparation
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
40. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. Topic is not used for eligibility determination.
41. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
42. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 11
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Shopping
43. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Shopping
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
44. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
45. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
46. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 12
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Transportation
47. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Transportation (how)
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
48. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
49. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
50. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 13
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Housework
51. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Ordinary Housework
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
52. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
53. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
54. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 14
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Money
55. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Managing Finances
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
56. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
57. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
58. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 15
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Telephone Use
59. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Phone Use
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
60. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
61. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
62. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 16
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Medications
63. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Managing Medications
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
IADL Performance & Capacity: Self-administering medications
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Medications: Adherent with medications prescribed by physician
64. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
65. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
Also require the medications code table for a list of medications.
6
66. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 17
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Employment
67. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Community and Social Involvement: Employment Status
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Community and Social Involvement: Employment arrangements (exclude volunteering)
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Community and Social Involvement: Person Prefers Change- Paid Employment
68. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
69. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
70. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 18
Domain: Medical Conditions/Diagnoses
71. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Disease Diagnosis: Asthma, Diabetes, Cancer, Cardiac, TBI, Mental Health, Other.
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Health Conditions: Falls
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Health Conditions: Pain Symptoms & Control
72. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
73. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
74. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 19
Domain: Cognitive Function & Memory/Learning
Topic: Cognitive Function
75. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Cognition: Cognitive Skills for Daily Decision Making
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Cognition: Memory Recall Ability (short term, procedural, and situational.)
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Cognition: Change in Decision Making as compared to 90 Days ago
76. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
77. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
78. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 20
Domain: Cognitive Function & Memory/Learning
Topic: Judgment/Decision­Making
79. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Cognition: Periodic Disordered Thinking or Awareness
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Cognition: Acute Change in Mental Status
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Cognition: Change in Decision Making as Compared to 90 Days Ago
80. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
81. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
82. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 21
Domain: Cognitive Function & Memory/Learning
Topic: Memory/Learning
83. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Cognition: Memory Recall Ability (short term/procedural/situational)
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
84. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
85. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
86. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 22
Domain: Behavior Concerns
Topic: Injurious Behavior
87. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Self-Injurious (biting, scratching, head banging, slapping, etc.)
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Violence (intimidation, threatened violence, acts of violence)
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Forensic Supplement: Intake and Prior Criminal History, Harm to Self or Others
88. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
89. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
90. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 23
Domain: Behavior Concerns
Topic: Destructive Behavior
91. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Physical Abuse/Aggression
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Verbal Abuse
Assessment Tool 3: Name
Assessment Tool 3: Questions
92. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
93. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
94. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 24
Domain: Behavior Concerns
Topic: Socially Offensive Behaviors
95. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Socially Inappropriate or Disruptive Behavior
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Inappropriate Public Sexual Behavior or Disrobing
Assessment Tool 3: Name
Assessment Tool 3: Questions
96. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
97. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
98. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 25
Domain: Behavior Concerns
Topic: Uncooperative Behavior
99. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior.: Resists Care
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Negative Statements
Assessment Tool 3: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 3: Questions
Mood and Behavior: Persistent Anger with Self or Others
100. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
101. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
102. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 26
Domain: Behavior Concerns
Topic: Other Serious Behavior
103. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Wandering/Elopement
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood & Behavior: Recurrent statements- Something terrible about to happen
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Mood & Behavior: Pica/Rumination/Polydipsia
104. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
105. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
106. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 27
Additional Topics (optional)
107. Topic: Instrumental Activities of Daily Living
108. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic. Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADLs Performance & Capacity: Stairs- how a full flight of stairs is managed.
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
IADLs Performance & Capacity: Basic Safety Procedures
Assessment Tool 3: Name
Assessment Tool 3: Questions
109. Which Balancing Incentive Program purposes do these questions address? Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination. This topic is not used for eligibility determination.
110. Do these questions meet the Balancing Incentive Program CSA requirements? Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements? 5
6
111. Do these questions meet the Balancing Incentive Program CSA recommendations? Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports­based, not deficits­based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions) 5
6
Page 28
Comments
Please use this page to provide any additional information.
112. Comments Eligibility determination is completed for an individual suspected of having a developmental disability 5
in accordance with New York State Mental Hygiene Law Section 1.03(22) and OPWDD policy prior
to the administration of the assessment. Therefore, no items on the assessment tool are used for
developmental disability eligibility determination.
While the items in the topic represent the key items for that topic, the assessment instrument
contains more items for many of the topics. It would be difficult to say whether the items listed
provide a summative view without a statistical review. Also, the assessment system produces
outcomes such as individualized goals, desire for change, scales and additional care planning
considerations that require domains, topics and items that are not addressed in the template.
The assessment instruments use empirical language designed to assess needs in a way which can
be validated. The items themselves include those which address strengths such as informal
supports and individual goals, for example. The assessment process involves more than Q&A; it
involves observation, discussion with the individual, family and/or review of documentation. The
selection options for many items begin with “independence” (described in terms of strengths) with 6
or more gradations. The outcomes include opportunities for improvement or prevention in addition
to the risk of decline and care needs.
6 113. More Comments The Intellectual and Developmental Disabilities determination of need for services is completed by
OPWDD to determine if a person's clinical record demonstrates a substantial disability and meets
the standards set forth in New York States Mental Hygiene Law 1.03 (22). This disability
determination is a separate and distinct process from the administration of the needs assessment,
known as the Coordinated Assessment System (CAS). Therefore, the OPWDD CAS (which is
based upon the interRAI ID/DD tool), will not be used in the Intellectual and Developmental
Disabilities determination process. Please note, the CAS will not be utilized as the needs
assessment tool until after the completion of a validity study. Anticipated completion is spring 2014.
5
6 Page 29
Balancing Incentive Program - Core Dataset Crosswalk
1. Please provide the following information:
CSA Contact:
Diane Woodward
Agency:
New York State Office For People With Developmental Disabilities
Address:
44 Holland Avenue, 4th Floor
Address 2:
City:
Albany
State:
NY
Zip:
12229
E-mail:
[email protected]
Phone:
518-486-4260
2. Pick a Population - Select the population(s) for which THIS Core Dataset Crosswalk applies.
*Please Note: The Core Dataset (CDS) must be collected for the following populations: developmental disability,
mental health, aging, and physical disability (across age groups). Other populations (e.g., Alzheimer’s, TBI) are
optional.
If you currently use (or intend to use) a single instrument to assess multiple populations, you should complete this
crosswalk once for all of those populations (e.g., aging and physical disability). In other words, you should complete
one instance of this crosswalk for every population or combination of populations that you assess (or plan to assess)
using the same set of questions.
Children
Adults
Developmental Disabilities
c
d
e
f
g
✔
c
d
e
f
g
✔
Mental Health
c
d
e
f
g
c
d
e
f
g
Physical Disabilities
c
d
e
f
g
c
d
e
f
g
Aging
c
d
e
f
g
c
d
e
f
g
Alzheimer's Disease
c
d
e
f
g
c
d
e
f
g
Traumatic Brain Injury
c
d
e
f
g
c
d
e
f
g
Other (please specify)
Page 1
Domain: Activities of Daily Living
Topic: Eating
3. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Eating
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Oral and Nutritional Status: Mode of Nutritional Intake
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Oral and Nutritional Status: Dental or Oral Issues
4. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic not used for eligibility determination.
5. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #122. Overall comments
6
6. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
See #112. Overall Comments regarding summative view.
See #112. Overall Comments regarding supports-based, not deficit based language.
5
6
Page 2
Domain: Activities of Daily Living
Topic: Bathing
7. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Bathing
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
8. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
9. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
10. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 3
Domain: Activities of Daily Living
Topic: Dressing
11. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Dressing Upper Body
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Self-Care Skills (ADL) Performance: Dressing Lower Body
Assessment Tool 3: Name
Assessment Tool 3: Questions
12. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
13. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
14. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 4
Domain: Activities of Daily Living
Topic: Hygiene
15. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Personal Hygiene (managing)
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Hygiene (poor)
Assessment Tool 3: Name
Assessment Tool 3: Questions
16. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
17. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
18. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 5
Domain: Activities of Daily Living
Topic: Toileting
19. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Toilet Use
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Health Conditions: Bowel Continence
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Health Conditions: Bladder Continence
20. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
21. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
22. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 6
Domain: Activities of Daily Living
Topic: Mobility
23. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Walking
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Self-Care Skills (ADL) Performance: Locomotion
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Self-Care Skills (ADL) Performance: Primary Mode of Locomotion/Walking
24. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
25. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
26. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 7
Domain: Activities of Daily Living
Topic: Positioning
27. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Bed Mobility
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
28. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
29. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
30. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 8
Domain: Activities of Daily Living
Topic: Transferring
31. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Self-Care Skills (ADL) Performance: Transfer Toilet
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
32. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
33. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
34. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 9
Domain: Activities of Daily Living
Topic: Communicating
35. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Communication & Vision: Making Self Understood
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Communication & Vision: Ability to Understand Others
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Communication & Vision: Communication Modes Used Daily
36. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
37. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
38. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 10
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Preparing Meals
39. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Meal Preparation
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
40. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
Topic is not used for eligibility determination.
41. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
42. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 11
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Shopping
43. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Shopping
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
44. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
45. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
46. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 12
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Transportation
47. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Transportation (how)
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
48. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
49. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
50. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 13
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Housework
51. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Ordinary Housework
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
52. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
53. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
54. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 14
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Money
55. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Managing Finances
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
56. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
57. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
58. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 15
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Telephone Use
59. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Phone Use
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
60. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
61. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
62. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 16
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Medications
63. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADL Performance & Capacity: Managing Medications
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
IADL Performance & Capacity: Self-administering medications
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Medications: Adherent with medications prescribed by physician
64. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
65. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
Also require the medications code table for a list of medications.
6
66. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 17
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Employment
67. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Community and Social Involvement: Employment Status
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Community and Social Involvement: Employment arrangements (exclude volunteering)
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Community and Social Involvement: Person Prefers Change- Paid Employment
68. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
69. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
70. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 18
Domain: Medical Conditions/Diagnoses
71. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Disease Diagnosis: Asthma, Diabetes, Cancer, Cardiac, TBI, Mental Health, Other.
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Health Conditions: Falls
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Health Conditions: Pain Symptoms & Control
72. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
73. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
74. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 19
Domain: Cognitive Function & Memory/Learning
Topic: Cognitive Function
75. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Cognition: Cognitive Skills for Daily Decision Making
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Cognition: Memory Recall Ability (short term, procedural, and situational.)
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Cognition: Change in Decision Making as compared to 90 Days ago
76. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
77. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
78. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 20
Domain: Cognitive Function & Memory/Learning
Topic: Judgment/Decision-Making
79. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Cognition: Periodic Disordered Thinking or Awareness
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Cognition: Acute Change in Mental Status
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Cognition: Change in Decision Making as Compared to 90 Days Ago
80. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
81. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
82. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 21
Domain: Cognitive Function & Memory/Learning
Topic: Memory/Learning
83. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Cognition: Memory Recall Ability (short term/procedural/situational)
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
84. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
85. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
86. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 22
Domain: Behavior Concerns
Topic: Injurious Behavior
87. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Self-Injurious (biting, scratching, head banging, slapping, etc.)
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Violence (intimidation, threatened violence, acts of violence)
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Forensic Supplement: Intake and Prior Criminal History, Harm to Self or Others
88. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
89. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
90. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 23
Domain: Behavior Concerns
Topic: Destructive Behavior
91. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Physical Abuse/Aggression
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Verbal Abuse
Assessment Tool 3: Name
Assessment Tool 3: Questions
92. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
93. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
94. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 24
Domain: Behavior Concerns
Topic: Socially Offensive Behaviors
95. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Socially Inappropriate or Disruptive Behavior
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Inappropriate Public Sexual Behavior or Disrobing
Assessment Tool 3: Name
Assessment Tool 3: Questions
96. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
97. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
98. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 25
Domain: Behavior Concerns
Topic: Uncooperative Behavior
99. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior.: Resists Care
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood and Behavior: Negative Statements
Assessment Tool 3: Name
interRAI Community Health Assessment /UAS-NY Community Assessment
Assessment Tool 3: Questions
Mood and Behavior: Persistent Anger with Self or Others
100. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
101. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
102. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 26
Domain: Behavior Concerns
Topic: Other Serious Behavior
103. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
Mood and Behavior: Wandering/Elopement
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
Mood & Behavior: Recurrent statements- Something terrible about to happen
Assessment Tool 3: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 3: Questions
Mood & Behavior: Pica/Rumination/Polydipsia
104. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
105. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
106. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 27
Additional Topics (optional)
107. Topic:
Instrumental Activities of Daily Living
108. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 1: Questions
IADLs Performance & Capacity: Stairs- how a full flight of stairs is managed.
Assessment Tool 2: Name
interRAI Intellectual Disability Tool/CAS- Coordinated Assessment System
Assessment Tool 2: Questions
IADLs Performance & Capacity: Basic Safety Procedures
Assessment Tool 3: Name
Assessment Tool 3: Questions
109. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
This topic is not used for eligibility determination.
110. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
111. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 28
Comments
Please use this page to provide any additional information.
112. Comments
Eligibility determination is completed for an individual suspected of having a developmental disability 5
in accordance with New York State Mental Hygiene Law Section 1.03(22) and OPWDD policy prior
to the administration of the assessment. Therefore, no items on the assessment tool are used for
developmental disability eligibility determination.
While the items in the topic represent the key items for that topic, the assessment instrument
contains more items for many of the topics. It would be difficult to say whether the items listed
provide a summative view without a statistical review. Also, the assessment system produces
outcomes such as individualized goals, desire for change, scales and additional care planning
considerations that require domains, topics and items that are not addressed in the template.
The assessment instruments use empirical language designed to assess needs in a way which can
be validated. The items themselves include those which address strengths such as informal
supports and individual goals, for example. The assessment process involves more than Q&A; it
involves observation, discussion with the individual, family and/or review of documentation. The
selection options for many items begin with “independence” (described in terms of strengths) with 6
or more gradations. The outcomes include opportunities for improvement or prevention in addition
to the risk of decline and care needs.
6
113. More Comments
5
6
Page 29
Appendix B.5: Crosswalk –OMH – CANS-NY
B.5-1
Balancing Incentive Program - Core Dataset Crosswalk
1. Please provide the following information:
CSA Contact:
Angela Keller
Agency:
NYS Office of Mental Health
Address:
Division of Children & Families
Address 2:
44 Holland Avenue, 8th Fl
City:
Albany
State:
NY
Zip:
12229
E-mail:
[email protected]
Phone:
(518) 473-6903
2. Pick a Population - Select the population(s) for which THIS Core Dataset Crosswalk applies.
*Please Note: The Core Dataset (CDS) must be collected for the following populations: developmental disability,
mental health, aging, and physical disability (across age groups). Other populations (e.g., Alzheimer’s, TBI) are
optional.
If you currently use (or intend to use) a single instrument to assess multiple populations, you should complete this
crosswalk once for all of those populations (e.g., aging and physical disability). In other words, you should complete
one instance of this crosswalk for every population or combination of populations that you assess (or plan to assess)
using the same set of questions.
Children
Adults
Developmental Disabilities
c
d
e
f
g
c
d
e
f
g
Mental Health
c
d
e
f
g
✔
c
d
e
f
g
Physical Disabilities
c
d
e
f
g
c
d
e
f
g
Aging
c
d
e
f
g
c
d
e
f
g
Alzheimer's Disease
c
d
e
f
g
c
d
e
f
g
Traumatic Brain Injury
c
d
e
f
g
c
d
e
f
g
Other (please specify)
Page 1
Domain: Activities of Daily Living
Topic: Eating
3. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Self-Care Daily Living Skills
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
4. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
5. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
6. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
See #112, Overall Comments, regarding a summative view (#6, first sub-question).
5
See #112, Overall Comments, regarding supports-based, not deficit based language (#6, second
sub-question).
6
Page 2
Domain: Activities of Daily Living
Topic: Bathing
7. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Self-Care Daily Living Skills
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
8. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
9. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
10. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 3
Domain: Activities of Daily Living
Topic: Dressing
11. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Self-Care Daily Living Skills
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
12. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
13. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
14. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 4
Domain: Activities of Daily Living
Topic: Hygiene
15. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Self-Care Daily Living Skills
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
16. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
17. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
18. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 5
Domain: Activities of Daily Living
Topic: Toileting
19. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Self-Care Daily Living Skills
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
20. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
21. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
22. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 6
Domain: Activities of Daily Living
Topic: Mobility
23. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Motor, Medical-Impairment functioning
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
24. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
25. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
26. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 7
Domain: Activities of Daily Living
Topic: Positioning
27. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Motor
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
28. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
29. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
30. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 8
Domain: Activities of Daily Living
Topic: Transferring
31. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Motor
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
32. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
33. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
34. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
.
5
6
Page 9
Domain: Activities of Daily Living
Topic: Communicating
35. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Primary Caregiver, Family, Communication
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
36. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
37. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
38. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 10
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Preparing Meals
39. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
40. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
41. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
42. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 11
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Shopping
43. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
44. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
45. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
46. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 12
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Transportation
47. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
48. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
49. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
50. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 13
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Housework
51. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
52. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
53. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
54. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 14
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Money
55. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
56. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
57. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
58. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 15
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Telephone Use
59. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
60. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
61. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
62. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 16
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Medications
63. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
64. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
65. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
66. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 17
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Employment
67. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
68. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
69. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
70. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
Since this domain is not required for children, no changes or additions to the CANS would be applicable.
5
6
Page 18
Domain: Medical Conditions/Diagnoses
71. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Behavioral Health Domain, Medical Health Domain, Substance Use Domain
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
72. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
73. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
74. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 19
Domain: Cognitive Function & Memory/Learning
Topic: Cognitive Function
75. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Developmental Domain
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
76. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
77. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
78. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 20
Domain: Cognitive Function & Memory/Learning
Topic: Judgment/Decision-Making
79. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Strengths Domain, Risk Behaviors Domain
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
80. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
81. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
82. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 21
Domain: Cognitive Function & Memory/Learning
Topic: Memory/Learning
83. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Life Functioning Domain, Developmental Domain,
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
84. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
85. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
86. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 22
Domain: Behavior Concerns
Topic: Injurious Behavior
87. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Risk Behaviors Domain
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
88. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
89. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
90. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 23
Domain: Behavior Concerns
Topic: Destructive Behavior
91. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Risk Behaviors Domain
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
92. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
93. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
94. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 24
Domain: Behavior Concerns
Topic: Socially Offensive Behaviors
95. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Risk Behaviors Domain
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
96. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
97. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
98. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 25
Domain: Behavior Concerns
Topic: Uncooperative Behavior
99. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Intentional Misbehavior
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
100. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
101. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
102. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 26
Domain: Behavior Concerns
Topic: Other Serious Behavior
103. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
CANS-NY
Assessment Tool 1: Questions
Risk Behaviors Domain, Adjustment to Trauma Domain
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
104. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
105. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
See #112, Overall Comments, eligibility determination (#5, second sub-question).
6
106. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 27
Additional Topics (optional)
107. Topic:
108. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
Assessment Tool 1: Questions
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
109. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
110. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
111. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 28
Comments
Please use this page to provide any additional information.
112. Comments
Eligibility determination - Programmatic eligibility determinations are defined by regulations and
guidelines and involve many more items than are included in this list of BIP domains. The
CANS-NY, as a validated instrument, in its totality along with supporting documentation collected at
time of referral/assessment determines eligibility for the HCBS Waiver. A CANS-NY algorithm
guides the "scoring" of the assessment to determine eligibility and level of care determination, in
addition to commencing of the service plan development. To list all of the items and logic of the
CANS-NY system is outside the scope and construct of this Crosswalk template.
5
Summative View - While the questions in the topic represent the key items for that topic, the
CANS-NY contains more items for many of the topics. It would be difficult to say whether the subset
of items listed provide a summative view without a statistical reivew. Also, the CANS-NY
assessment produces outcomes that are not addressed in the template.
Supports-based Language - The CANS-NY uses empirical language designed to assess needs and
strengths that has been validated. The items themselves include those which address strengths
such as informal supports and individual goals, for example. The assessment process involves more
than just questions/answers; it involves observation, discussion with the individual, family and other
providers, and review of documentation. The selection options within each domain/topic have four
gradations.
6
113. More Comments
Throughout NYS, the CANS-NY is used as an assessment/planning tool for the HCBS Waiver
program in all but one county (i.e., Erie). Erie County utilizes the CAFAS which is a validated tool
that has similar domains as the CANS-NY. By the anticipated end of the BIP project specific to
HCBS Waiver, all counties will be required to transition to the CANS-NY and utilize an identical
process to comply with all BIP requirements.
5
6
Page 29
Appendix B.6: Crosswalk –OMH - CDS
B.6-1
Balancing Incentive Program - Core Dataset Crosswalk
1. Please provide the following information:
CSA Contact:
Jim Gratton; Angela Keller,
Agency:
NYS Office of Mental Health
Address:
44 Holland Ave
Address 2:
City:
Albany
State:
NY
Zip:
12229
E-mail:
[email protected]
Phone:
518-473-1066
2. Pick a Population - Select the population(s) for which THIS Core Dataset Crosswalk applies.
*Please Note: The Core Dataset (CDS) must be collected for the following populations: developmental disability,
mental health, aging, and physical disability (across age groups). Other populations (e.g., Alzheimer’s, TBI) are
optional.
If you currently use (or intend to use) a single instrument to assess multiple populations, you should complete this
crosswalk once for all of those populations (e.g., aging and physical disability). In other words, you should complete
one instance of this crosswalk for every population or combination of populations that you assess (or plan to assess)
using the same set of questions.
Children
Adults
Developmental Disabilities
c
d
e
f
g
c
d
e
f
g
Mental Health
c
d
e
f
g
c
d
e
f
g
✔
Physical Disabilities
c
d
e
f
g
c
d
e
f
g
Aging
c
d
e
f
g
c
d
e
f
g
Alzheimer's Disease
c
d
e
f
g
c
d
e
f
g
Traumatic Brain Injury
c
d
e
f
g
c
d
e
f
g
Other (please specify)
Page 1
Domain: Activities of Daily Living
Topic: Eating
3. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
ADL Self-Performance: Eating
Assessment Tool 2: Name
interRAI Community Mental Health (CMH)
Assessment Tool 2: Questions
Nutritional Status
Assessment Tool 3: Name
Assessment Tool 3: Questions
4. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
5. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
6. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 2
Domain: Activities of Daily Living
Topic: Bathing
7. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
ADL Self-Performance-Personal Hygiene
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
8. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
9. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
10. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 3
Domain: Activities of Daily Living
Topic: Dressing
11. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment (CHA)
Assessment Tool 1: Questions
ADL Self-Performance-Dressing Upper Body; Dressing Lower body
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
12. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
13. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
14. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 4
Domain: Activities of Daily Living
Topic: Hygiene
15. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health
Assessment Tool 1: Questions
DL Self-Performance: Personal Hygiene
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
16. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
17. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
18. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 5
Domain: Activities of Daily Living
Topic: Toileting
19. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
ADL Self-Performance: Toilet Use
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
20. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
21. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
22. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 6
Domain: Activities of Daily Living
Topic: Mobility
23. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
ADL Self-Performance: Locomotion
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
24. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
25. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
26. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 7
Domain: Activities of Daily Living
Topic: Positioning
27. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Health Assessment (CHA)
Assessment Tool 1: Questions
ADL Self-Performance-Bed mobility
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
28. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
29. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
30. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 8
Domain: Activities of Daily Living
Topic: Transferring
31. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health
Assessment Tool 1: Questions
ADL Self-Performance: Transfer Toilet
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
32. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
33. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
34. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 9
Domain: Activities of Daily Living
Topic: Communicating
35. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Making Self Understood
Assessment Tool 2: Name
interRAI Community Mental Health (CMH)
Assessment Tool 2: Questions
Ability to Understand Others
Assessment Tool 3: Name
interRAI Community Mental Health (CMH)
Assessment Tool 3: Questions
Hearing/Vision
36. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
Assessment Tool #2
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Note here if this topic is not used for eligibility determination.
37. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
38. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 10
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Preparing Meals
39. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
IADL Self-Performance: Meal Preparation
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
40. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
41. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
42. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 11
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Shopping
43. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
IADL Self-Performance: Shopping
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
44. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
45. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
46. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 12
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Transportation
47. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
IADL Self-Performance: Transportation
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
48. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
49. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
50. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 13
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Housework
51. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
IADL Self-Performance and Capacity-Ordinary Housework
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
52. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
53. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
54. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 14
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Money
55. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
IADL Self-Performance: Managing Finances
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
56. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
57. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
58. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 15
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Telephone Use
59. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
IADL Self-Performance: Phone use
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
60. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
61. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
62. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 16
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Managing Medications
63. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
IADL Self-Performance: Managing Medications
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
64. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
65. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
66. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 17
Domain: Instrumental Activities of Daily Living (not required for children)
Topic: Employment
67. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Employment, Education, and Finances
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
68. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
69. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
70. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 18
Domain: Medical Conditions/Diagnoses
71. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Health Conditions; Diagnostic Information
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
72. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
73. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
74. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 19
Domain: Cognitive Function & Memory/Learning
Topic: Cognitive Function
75. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Cognitive Skills for Daily Decision Making; Memory/Recall Ability
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
76. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
77. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
78. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 20
Domain: Cognitive Function & Memory/Learning
Topic: Judgment/Decision-Making
79. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Periodic Disorder Thinking or Awareness; Acute Change in Mental Status
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
80. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
81. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
82. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 21
Domain: Cognitive Function & Memory/Learning
Topic: Memory/Learning
83. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Memory/Recall Ability
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
84. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
85. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
86. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 22
Domain: Behavior Concerns
Topic: Injurious Behavior
87. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Self-Injurious Ideation or Attempt; Violence to others
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
88. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
89. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
90. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 23
Domain: Behavior Concerns
Topic: Destructive Behavior
91. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Behavior Symptoms: Physical Abuse; Verbal Abuse; Socially inappropriate/disruptive
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
92. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
93. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
94. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 24
Domain: Behavior Concerns
Topic: Socially Offensive Behaviors
95. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Behavior Symptoms: Socially Inappropriate or Disruptive Behavior
Assessment Tool 2: Name
Assessment Tool 2: Questions
Behavior Symptoms: Inappropriate Public Sexual Behavior or Disrobing
Assessment Tool 3: Name
Assessment Tool 3: Questions
96. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
97. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
98. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 25
Domain: Behavior Concerns
Topic: Uncooperative Behavior
99. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Behavior Symptoms: Resists Care
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
100. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
101. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
102. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 26
Domain: Behavior Concerns
Topic: Other Serious Behavior
103. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Behavior Symtoms: Wandering; Persistent anger with self/others;Substance Use
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
104. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
✔
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
105. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
106. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 27
Additional Topics (optional)
107. Topic:
Mental Status
108. Identify the assessment tool(s), and the questions from each tool that you propose to use to assess this topic.
Assessment Tool 1: Name
interRAI Community Mental Health (CMH)
Assessment Tool 1: Questions
Mental Status
Assessment Tool 2: Name
Assessment Tool 2: Questions
Assessment Tool 3: Name
Assessment Tool 3: Questions
109. Which Balancing Incentive Program purposes do these questions address?
Eligibility determination
Identification of support needs
Informing support planning
Assessment Tool #1
c
d
e
f
g
c
d
e
f
g
✔
c
d
e
f
g
✔
Assessment Tool #2
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Assessment Tool #3
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Note here if this topic is not used for eligibility determination.
110. Do these questions meet the Balancing Incentive Program CSA requirements?
Yes
No
The questions are adequate to assess the topic for this population across all portions of the state
j
k
l
m
n
j
k
l
m
n
The questions meet at least 2 of the 3 CSA purposes (i.e., to determine eligibility, identify support
j
k
l
m
n
j
k
l
m
n
needs, and/or inform support planning)
What further actions are needed, if any, to meet these requirements?
5
6
111. Do these questions meet the Balancing Incentive Program CSA recommendations?
Yes
No
The question set provides a summative view of the individual's support needs for this topic.
j
k
l
m
n
j
k
l
m
n
The questions use supports-based, not deficits-based language
j
k
l
m
n
j
k
l
m
n
What further actions are needed, if any, to meet these recommendations? (e.g., involve stakeholders to review tools, identify new questions)
5
6
Page 28
Comments
Please use this page to provide any additional information.
112. Comments
The interRAI Community Mental Health tool also assesses for Stress and Trauma, Service
Utilization and Treatments, Social Relations, provides an Environmental assessment, and considers
level of care/community intergration opportunities.
5
Programmatic eligibility determinations defined by statute and regulations involve more items than
are included in these domains.
While the items in the topic represent the key items for that topic, the assessment instrument
contains more items for many of the topics. It would be difficult to say whether the items listed
provide a summative view without a statistical review. Also, the assessment system will produce
outcomes such as individualized goals, desire for change, scales and additional care planning
considerations that require domains, topics and items that are not addressed in the template.
The assessment instruments use empirical language designed to assess needs in a way which can
be validated. The items themselves include those which address strengths such as informal
supports and individual goals, for example. The assessment process involves more than Q&A; it
involves observation, discussion with the individual, family and/or review of documentation. The
selection options for many items begin with “independence” (described in terms of strengths) with 6
or more gradations. The outcomes include opportunities for improvement or prevention in addition
to the risk of decline and care needs.
6
113. More Comments
5
6
Page 29
Appendix C.1: Conflict Free Case Management
C.1-1
Balancing Incentive Program: Conflict-Free Case Management
With the Work Plan, Balancing Incentive Program States are required to submit a description of areas of possible conflict in case management and systems the
State currently has in place to mitigate those conflicts. States may fill out this form to fulfill this deliverable requirement.
1. For each Waiver/State Plan Program (column A), indicate which entity(ies) provides each service by filling out the below table. You may add
rows to the table.
A. Waiver/State
Plan Program
B. Entity that conducts
functional assessments
C. Entity that provides
case management
D. Service provider
types
MLTC Plans and MLTC
contracted vendors
MLTC Plans
CHHAs, LTHHCPs,
E. Comments
DOH:
Managed Long Term
Care (MLTC)
Licensed Home Care
Services Agencies
(LHCSAs) and others.
Long Term Home
Health Care Program
(LTHHCP)
RN from the LTHHCP and
representative from the
LDSS; Hospital Discharge
Planner,
LTHHCP
CHHA, Nursing
Home, or Hospital
with NYS DOH
certification to provide
a LTHHCP.
Traumatic Brain Injury
(TBI) Waiver
RN; RRDC representative
NYS DOH contracted
vendors
Approved Waiver
Providers include
LHCSAs, RNs,
Certified
Rehabilitation
Counselors,
Physical/Occupational
Therapists, Master
Social Workers
(MSWs) and Masters
in Counseling.
C.1-2
A. Waiver/State
Plan Program
B. Entity that conducts
functional assessments
C. Entity that provides
case management
D. Service provider
types
Nursing Home
Transition and
Diversion (NHTD)
Waiver
Registered Nurse (RN);
Waiver provider for service
coordination
Service providers
vary, depending on the
service delivered, e.g.,
Assistive Technology,
E-Mods and Home
Delivered Meals.
Care at Home Waivers
I & II
LDSS, NYC HRA, Care at
Home (CAH) Coordinator,
Assessing Agency, Case
Managers.
NYS DOH Contracted
service coordination entity.
LTHHCP, CASA,
LDSS,
residential health care
facility (RHCF)
E. Comments
Assessment infrastructure is
identical to the TBI waiver.
Developmental
Disabilities Services
Office (DDSO),
Approved Professional
Case Management
Agencies, Parent or
Guardian, RNs.
Assisted Living
Program (ALP)
ALP conducts initial and
functional assessment or
contracts with CHHA for
functional Assessment.
ALP/LDSS
The ALP, a Certified
Home Health Agency
(CHHA) or LTHHCP.
Adult Day Health Care
Program (ADHCP)
Physician recommendation
needed for admission;
ADHCP staff (nurse and/or
social worker) conducts preadmission assessment with
reassessments required at
least every 6 months.
ADHCP staff; waiver staff
Primarily Nursing
Homes operate
ADHCPs, but a
diagnostic and
treatment center may
also operate an
ADHCP.
Personal Care Services
Program(PCSP)
LDSS once Physician orders
are received; nursing and
social assessment is
completed
Local Department of Social
Services.
CHHA; LHCSA.
Directed Personal
Assistance Program
(CDPAP)
LDSS
LDSS
CHHA; LHCSA
(fiscal intermediary)
Consumer hires and manages
his own attendant.
C.1-3
A. Waiver/State
Plan Program
B. Entity that conducts
functional assessments
C. Entity that provides
case management
D. Service provider
types
The DISCO is ultimately
responsible for case
management. The DISCO
may contract out for certain
case management functions.
Note: if a DISCO chooses to
contract with an entity for
case management (CM)
functions, the entity must
either NOT participate as a
network provider OR have
appropriate firewalls between
its CM and service provision
functions.
Voluntary providers
who meet criteria
specified in the
1915(c) waiver for
long term care
supports and services.
In managed care, the
provider network
capacity requirements
will be defined in the
RFA and reviewed by
OPWDD as part of the
readiness review and
ongoing quality
review and oversight
process.
E. Comments
OPWDD:
OPWDD (all programs
serving children and
adults)
Providers of Service
OMH:
OMH Children’s
Waiver
SPOA/LGU and lead Waiver HCBS Waiver lead agency
provider, however SPOA/
LGU approve eligibility
Private, voluntary
agency
OMH Children (fee for
service – ICM
(intensive case
management), SCM
(supportive case
management) and
BCM (blended case
management)
The CANS-NY is completed
by the SPOA/LGU and by
the case management
provider.
Private, voluntary
agencies, county
operated programs and
State OMH items
Intensive Case Management,
Supportive Case Management
and Blended Case
Management providers
C.1-4
A. Waiver/State
Plan Program
B. Entity that conducts
functional assessments
C. Entity that provides
case management
D. Service provider
types
OMH Children (fee for Committees on Special
Not applicable
service) Day
Education (CSE) within each
Treatment
School District, with
education/treatment team
input.
State-Operated, notfor-profits, County
and Article 28s
OMH Children (fee for RTF
service) – Residential
Treatment Center
(RTF)
RTF is a subclass of inpatient
services, therefore billing is
by an all-inclusive daily rate.
All services are provided
within the RTF structure,
therefore, the RTF manages
services while the child is
within the RTF.
Voluntary not for
profits
OMH Children (fee for Open referral process.
service) – Seriously
Various assessment tools
Emotionally
undertaken upon intake.
Disturbance (SED)
Clinic
Varies dependent on need.
State-operated, not for
profits, County
government, Article
28s
OMH Adults
Independent Entity to be
determined
Health Home and Managed
Care Organization (MCO)
State Plan,
Mainstream Plans,
Health and Recovery
Plan (HARP)
Networks
OASAS Adolescents
and Adults
Independent entity to be
determined
Health Home and MCO
State Plan,
Mainstream Plans,
HARP Networks
E. Comments
C.1-5
2. If there is overlap between columns B and D or columns C and D in the above table, please indicate why there is overlap by placing an “X” in the
appropriate box.
A. Waiver/State
Plan Program
B. Rural
area
C. Provider
capacity
D. Managed
care
X
X
E. Structural
F. Beneficiary
choice
G. Other
DOH:
Managed Long Term
Care
Long Term Home
Health Care Program
TBI Waiver
NHTD Waiver
Care at Home Waivers
I and II
Assisted Living
Program
Adult Day Health Care
Personal Care
Consumer Directed
Personal Assistant
Program
Bridges to Health
(OCFS)
C.1-6
A. Waiver/State
Plan Program
B. Rural
area
C. Provider
capacity
D. Managed
care
E. Structural
F. Beneficiary
choice
G. Other
OPWDD:
OPWDD (all programs
serving children and
adults)
X
X
Benefit to
maintaining the
continuity of
current case
management
provider and to
honor the
informed choice
of the individual.
OMH:
OMH Children’s
Waiver
The initial
service
plan
developed
by the
HCBS
Waiver
lead
agency
must be
reviewed
and
approved
by the
LGU
OMH Children (fee for SPOA/
service)
LGU
determines
Level of
Care from
review of
C.1-7
A. Waiver/State
Plan Program
B. Rural
area
C. Provider
capacity
D. Managed
care
E. Structural
F. Beneficiary
choice
X
X
X
X
Grievances,
complaints,
appeals, and
resulting
decisions will be
adequately
tracked,
monitored and
used, including
clear, wellknown and
accessible
pathways for
these activities.
The assessments being
developed will be data
driven, standardized, and
contain a core data set.
G. Other
CANS-NY
information
for every
child
OMH Adults
X
There will be
robust
monitoring by
State quality
management
staff.
Administra
tive
firewalls
will
separate
eligibility
determinati
on from
service
provision.
There will be
robust
monitoring by
State quality
management
staff.
3. If there is overlap between columns B and D or columns C and D in the first table, please indicate the strategies you have in place to mitigate
conflict by placing an “X” in the appropriate box.
A. Waiver/State
Plan Program
B. Admin
firewalls
C. State
approval of
plans of
care
D. State
monitorin
g through
analysis of
referrals
E. State
monitoring
through
survey of
beneficiary
satisfaction
F. Beneficiary
complaint system
G. Datadriven
assessments
H. Other
DOH:
Managed Long Term
Care
X
X
C.1-8
A. Waiver/State
Plan Program
B. Admin
firewalls
C. State
approval of
plans of
care
D. State
monitorin
g through
analysis of
referrals
E. State
monitoring
through
survey of
beneficiary
satisfaction
F. Beneficiary
complaint system
G. Datadriven
assessments
H. Other
Long Term Home
Health Care Program
TBI Waiver
NHTD Waiver
Care at Home
Waivers I and II
Assisted Living
Program
Adult Day Health
Care
Personal Care
Consumer Directed
Personal Assistant
Program
Bridges to Health
(OCFS)
C.1-9
A. Waiver/State
Plan Program
D. State
monitorin
g through
analysis of
referrals
E. State
monitoring
through
survey of
beneficiary
satisfaction
B. Admin
firewalls
C. State
approval of
plans of
care
X
X
X
DISCOs will
have separate
departments
that perform
case
management
functions and
service
authorization.
Administration or
review and
verification of the
assessment by
OPWDD regional
office staff.
OPWDD
conducts annual
surveys of all
services, which
includes surveys
of the
individual.
OPWDD is
developing a
specific
satisfaction
survey for all
DISCO
enrollees; the
satisfaction
survey will be
based on both
the National
Core Indicators
survey and The
Council on
Quality and
Leadership’s
(CQL) Personal
Outcome
Measures
(POMs).
G. Datadriven
assessments
H. Other
X
X
X
In accordance with
Article 44 of the NYS
Public Health Law, there
will be a grievances and
appeals process with
which DISCOs must
comply. DISCOs will
be required to report to
the State on a quarterly
basis a summary of all
grievances and appeals
that were received in
that quarter.
OPWDD is
working to
develop the
Informatio
n
Technolog
y (IT)
infrastructure for the
CAS data;
will be
used to
determine
acuity
levels and
identify
needs for
service
planning.
All persons
eligible to
receive
service
coordinatio
n (MSC)
and or
waiver
services are
educated
on the
options and
service
providers
available to
them.
F. Beneficiary
complaint system
OPWDD:
OPWDD (all
programs serving
children and adults)
Supervisory
lines between
departments
will not cross.
Freedom of
choice when
choosing a
service
coordinator
(MSC).
OPWDD and DOH will
monitor the DISCOs’
processing and
resolution of grievances.
OPWDD will implement
an Ombudsman Program
that will provide
assistance with
grievance and appeals
procedures.
Individuals
can then
choose
their
service
coordinatio
n provider
and the
service
coordinator
.
Further,
OPWDD will
continue to
C.1-10
A. Waiver/State
Plan Program
B. Admin
firewalls
C. State
approval of
plans of
care
D. State
monitorin
g through
analysis of
referrals
E. State
monitoring
through
survey of
beneficiary
satisfaction
F. Beneficiary
complaint system
G. Datadriven
assessments
H. Other
annually audit
all downstream
providers
through surveys,
site visits, and
desk reviews.
OMH:
OMH Children’s
Waiver
The initial
service plan
developed by
the HCBS
Waiver lead
agency must
be reviewed
and approved
by the LGU
OMH Adults
X
Administrativ
e firewalls
will separate
eligibility
determination
from service
provision.
X
There will be
robust
monitoring by
State quality
management
staff.
X
There will be
robust
monitoring by
State quality
management
staff.
X
Grievances, complaints,
appeals, and resulting
decisions will be
adequately tracked,
monitored and used,
including clear, wellknown and accessible
pathways for these
activities.
X
The
assessment
s being
developed
will be data
driven,
standardize
d and
contain a
core data
set.
C.1-11
Appendix D: Data Collection and Reporting
D-1
Balancing Incentive Program: Data Collection Requirements
Balancing Incentive Program States are required to collect three types of data: service data, quality data linked to population-specific outcomes, and
outcomes measures. As part of their Work Plan deliverables, States must report to CMS the data and measures that will be collected and the
methodology for collecting those measures.1 States may complete this form to fulfill Work Plan requirements.
State: New York
State contact (name and email address): Karen Ambros
Date of submission: 8/30/2013
1.
SERVICE DATA
Community LTSS service providers should report to the State all community LTSS services eligible for the Balancing Incentive Program enhanced
FMAP an individual receives at the individual level.
1.1. Type of data collected
☒Claims data submitted by community LTSS providers
☒Encounter data submitted by MCOs
☒Other: Cost reports by MCOs.
1
States will not be required to submit the collected data directly to CMS, though CMS reserves the right to request these data at any time.
D-2
1.2. Please briefly describe the types of reports already created or that will be created with these data for community LTSS administrative/financial or
quality control purposes.
Report name
Purpose
Frequency
Date of last
report*
CMS 64 reports
These reports are created and used routinely on a
statewide basis for Medicaid Claiming for
enhanced Federal Medical Assistance Percentage
(FMAP).
☒Quarterly
8/15/13
These reports will be used as a basis for reporting
the baseline percentage (for community LTSS
expenditures) and the semiannual updates for BIP.
The information on these reports is supported by
recipient level detail.
☐Other:
These reports are submitted from Managed Care
Organizations and Managed Long Term Care
Organizations and used by NYS routinely for a
number of purposes. They reflect organization’s
actual costs for services and administration.
☒Quarterly
Quarterly and
Annual Cost
Reports
☐Annually
☐Ad hoc
6/30/13
☐Annually
☐Ad hoc
☐Other:
These reports will be used as a basis to calculate
and proxy some adjustments (and reclassifications)
to the CMS 64 expenditures. The adjustments and
reclassifications are necessary for an accurate
representation of community LTSS under BIP
reporting definitions.
These reports provide a certain level of detail for
service categories which the CMS 64 reports do
not provide.
Stage 2 Streamlined Eligibility 1
D-3
Report name
Purpose
Frequency
Date of last
report*
Ad hoc Reports
from Data
Warehouse source.
These reports are and will be generated quarterly
and used as basis to calculate and proxy some
reclassifications to the CMS 64 expenditures
claiming and baseline calculation for BIP. The
adjustments and reclassifications are necessary for
an accurate representation of community LTSS
under BIP reporting definitions.
☒Quarterly
8/15/13
☐Annually
☐Ad hoc
☐Other:
These reports provide a certain level of detail for
service categories which the CMS 64 and cost
reports do not provide.
The information on these reports is supported by
recipient level detail.
Ad hoc Reports
from encounter
data
Managed Care Organizations and Managed Long
Term Care Organizations report encounters and
other utilization data and is used routinely by NYS
for a number of purposes which relate to quality
and fiscal controls on organizations expenditures.
☐Quarterly
☒Annually
☐Ad hoc
Collected
continually
every day, not
quarterly.
☐Other:
This data is not used directly for BIP reporting.
The information on these reports is supported by
recipient level detail.
* If reports are not already developed, please input the date when you expect them to be developed.
D-4
1.3. Describe progress and anticipated challenges.
Describe progress toward implementing this measure:
Completed
Describe experienced or anticipated challenges to implementing this measure:
Not applicable
Describe the State's plan to address the challenges described above:
Not applicable.
D-5
2. QUALITY DATA
Quality data include clinical measures that capture the extent to which service providers are supplying comprehensive, quality care.
2.1. Please briefly describe the instruments used or that will be used to calculate quality measures.
Measure instrument
Population
Frequency of
calculation
Date of last
calculation*
☐Medicaid Adult Health Quality Measures
☒ Elderly individuals
☐Quarterly
☐Homegrown, Name:
☐People with developmental
disabilities
☒Annually
☐Other:
January 2013
with SAAM
data. The first
calculation with
UAS-NY data
is expected to
be in July 2014
with subsequent
calculations in
January.
June 2013
☒ Other, Name: Home Care Quality Indicators
(HCQIs) generated from UAS-NY assessment
data (replacing those currently generated from
Semi-Annual Assessment of Members
☐People with serious mental illness
☒ People with physical disabilities
☐Ad hoc
(SAAM ) assessment data)
☐Other
☐Medicaid Adult Health Quality Measures
☒Elderly individuals
☐Quarterly
☐Homegrown, Name:
☐People with developmental
disabilities
☐People with serious mental illness
☒Annually
☒Other, Name: NCQA (National Committee
for Quality Assurance) HEDIS (Healthcare
Effectiveness Data and Information Set)
generated by eMEDNY claims data
☒People with physical disabilities
☐Ad hoc
☐Other:
☐Other
D-6
Measure instrument
Population
Frequency of
calculation
Date of last
calculation*
☐Medicaid Adult Health Quality Measures
☐Elderly individuals
☒Quarterly
☒Homegrown, Name: Phase I Behavioral
Health Organizations Metrics
☐Other, Name:
☐People with developmental
disabilities
☒People with serious mental illness
☐Annually
Quarter 4 of
2012.
Calculated for
fee-for-service
behavioral
health
recipients. Will
be replaced
with Phase II
metrics once
additional
behavioral
health services
are carved into
managed care.
2013 Collection
ends 9/30.
☐People with physical disabilities
☐Ad hoc
☐Other:
☐Other
☐Medicaid Adult Health Quality Measures
☐Elderly individuals
☐Quarterly
☐Homegrown, Name:
☒People with developmental
disabilities
☒Annually
☒Other, Name: National Core Indicators
(NCIs), personal interview protocol
☐People with serious mental illness
☐People with physical disabilities
☐Ad hoc
☐Other:
☐Other
☐Medicaid Adult Health Quality Measures
☐Elderly individuals
☐Quarterly
☒Homegrown, Name: Restrictive
Interventions Application (RIA)
☒People with developmental
disabilities
☐Annually
☐Other, Name:
☐People with serious mental illness
☐People with physical disabilities
☐Other
☐Ad hoc
☒Other:
N/A – ‘live’
database,
monitored
quarterly for
report out on
the use of
physical
interventions.
D-7
Measure instrument
Population
Frequency of
calculation
Date of last
calculation*
☐Medicaid Adult Health Quality Measures
☐Elderly individuals
☐Quarterly
☒Homegrown, Name: Incident Report and
Management Application (IRMA)
☐Other, Name
☒People with developmental
disabilities
☐People with serious mental illness
☐Annually
N/A - – ‘live’
database,
monitored
quarterly for
statewide
tracking of
reportable
incidents,
including abuse
or neglect
allegations.
First data
collection was
May 13, 2013
and only
includes the
FACT GP and
HH Functional
Assessment.
Analysis is in
process. Next
quarter
submission is
August 5, 2013.
UAS will be
introduced in
Long Term
Care providers
starting in
October 2013.
☐People with physical disabilities
☐Ad hoc
☒Other:
☐Other
☐Medicaid Adult Health Quality Measures
☐Elderly individuals
☒Quarterly
☒Homegrown, Name: Health Home Care
Management Assessment Reporting Tool (HH
CMART) which is also used as a convenience
collection tool for the FACT GP and Health
Home Functional Assessment
☐Other, Name:
☒People with developmental
disabilities
☐People with serious mental illness
☐Annually
☐Medicaid Adult Health Quality Measures
☒Elderly individuals
☐Quarterly
☐Homegrown, Name:
☐People with developmental
disabilities
☐People with serious mental illness
☒Annually
☒Other, Name: Universal Assessment System
☐People with physical disabilities
☐Ad hoc
☐Other:
☒Other High risk persons with chronic
illness.
☐People with physical disabilities
☐Ad hoc
☐Other:
☐Other
* If measures have not yet been calculated, please input the date when you expect them to be calculated.
D-8
2.2. Will results be made available to community LTSS providers?
☒Yes
☐ No
2.3. If so, briefly describe the process for making these results available: The HCQIs are currently calculated systematically using SAAM data and
checked by the Office of Quality and Patient Safety (OQPS). Once reviewed, the results for all plans are published in the Managed Long Term
Care Report which is made available on a public website. In addition, the “crude” HCQI reports (not risk adjusted) which contain plan-specific
data are distributed to the respective plans. The HCQI’s will be calculated with data generated from the UAS-NY in 2014. This data will be
published as described above except plans will be able to access their “crude” HCQI reports directly from the UAS-NY. The NCQA data is
submitted by Medicaid Advantage Plans (MAP’s) to CMS first and is not distributed back to plans by NYS. HEDIS/QARR measures are
calculated by managed care plans and submitted to NYS DOH. Plan level data is available through eQARR and Managed Care Plan
Performance Reports on the NYS DOH website. A data portal is available on the OMH website for the Phase I Behavioral Health Organizations
metrics. OPWDD’s NCI data is not routinely shared with providers because it is used to calculate statewide measures and not tied to the
representation of particular providers. These system measures are shared in various forums on an ad-hoc basis. The Restrictive Interventions
Application data is currently being made available to providers directly from the application and as it pertains to them. The IRMA data is
directly assessable to providers; they can pull their own data from the system. For the Health Home CMART and FACT GP, relevant providers
will be provided specific reports with their data and a comparison to relevant rolled up State data. A final report with all summations of data
may be made available to the interested public as part of the assessment of Health Homes. This is a new tool that will need a period of
evaluation so early results may not sufficiently represent relevant information for Health Homes.
2.4. Describe progress and anticipated challenges.
Describe progress toward implementing this measure:
NYS has compiled the list of quality data collected for its programs and their populations together
with the frequency and last collection date (described above) and also has begun collecting a single
catalog of quality data indicators used for its Medicaid populations.
D-9
Describe experienced or anticipated challenges to implementing this measure:
Historically NYS has approached quality data collection and related measures from a programmatic
rather than a population perspective. As such there are no interagency mechanisms to evaluate
whether a uniformity or common data set is feasible and, if so, what the effort to achieve such
commonality would be.
Describe the State's plan to address the challenges described above:
In response to the BIP requirement, NYS has identified an interagency team for the compilation and
cataloging of quality data. This team will review the current compilation (described above) as well as
any new requirements in order to evaluate whether commonalities for populations can be achieved.
3. OUTCOME MEASURES
States should collect outcomes measures by population to assess beneficiary and family caregiver experience and satisfaction with providers. Data should also
be collected regarding activities that help individuals achieve higher quality of life, including employment, participation in community life, health stability, and
prevention of loss in function.
D-10
3.1. Please briefly describe the instruments used or that will be used to calculate outcomes measures.
Survey
instrument
Purpose
Use of sample
Frequency of data
collection/analysis
Date of last data
collection/analysis*
NYSDOH/ Island
The member satisfaction survey is
used to assess member/family
caregiver experience with plan
services, member health
outcomes, quality ratings for key
services, timeliness of critical
services, access to critical
services, plan rating, and advance
directives.
☐ 100%
☐Quarterly
2011
☐ Representative sample
☐Annually
☐ Stratified sample
☐Ad hoc
☒ Other
Managed Long Term Care
members including
☒Other: Every two years
Peer Review
Organization
(IPRO) Managed
Long Term Care
Member
Satisfaction
Survey
Program of All Inclusive
Care for the Elderly
(PACE), Medicaid
Advantage Plus and Partial
Capitation.
The UAS-NY
assessment system
The UAS-NY is used to assess
individual’s community Long
Term Care) LTC needs largely for
the aged and physically disabled
populations. The system includes
domains involving employment
and participation in community
life. It also produces outcomes
about an individual’s health
stability and prevention of loss in
function.
☐ 100%
☐Quarterly
☐ Representative sample
☐Annually
☐ Stratified sample
☒Ad hoc
☒ Other Assessments are
generally conducted every
6 mos. However, the
employment and
community life domains
may not always be
completed.
☒Other: The UAS-NY is
currently in the
implementation phase with
a plan for statewide
implementation for 8
programs by 2/2014.
N/A
D-11
Survey
instrument
Purpose
Use of sample
Frequency of data
collection/analysis
Date of last data
collection/analysis*
interRAI
Community
Mental Health
Assessment
To determine eligibility for
1915(i) services in Health and
Recovery Plans. Information
related to social outcomes
(employment, housing stability,
criminal justice involvement) will
be collected.
☒ 100%
☐Quarterly
☐ Representative sample
☐Annually
Data collection will begin
in early 2015 and analysis
date is to be determined.
☐ Stratified sample
☐Ad hoc
☐ Other
☒ Other: Data collection
will be ongoing.
☐ 100%
☐Quarterly
☒ Representative sample
☒ Annually
☐ Stratified sample
☐Ad hoc
☐ Other
☒ Other: The transition
survey will be a one-time
survey.
Consumer
Satisfaction
Surveys
(Consumer
Assessment of
Healthcare
Providers and
Systems
(CAHPS),
Member
Transition Survey,
and a Behavioral
Health
Supplemental
Survey)
To determine member satisfaction
with managed care plans and ease
of transition into managed care
plans.
Data collection for
consumer surveys will
begin in late 2015 and the
analysis date is to be
determined.
D-12
Survey
instrument
Purpose
Use of sample
Frequency of data
collection/analysis
Date of last data
collection/analysis*
OMH Consumer
Assessment of
Care
This survey assesses the
perception of care among adults
in state operated outpatient
programs.
☐ 100%
☐Quarterly
2012 data is now
available.
☐ Representative sample
☒ Annually
☐ Stratified sample
☐Ad hoc
☒ Other: Adults who
received treatment from
State operated outpatient
programs during a
specified time period were
surveyed.
☐Other: .
☐ 100%
☐Quarterly
☐ Representative sample
☒ Annually
☐ Stratified sample
☐Ad hoc
☒ Other: Youth who
received treatment during
a specified time period
from a convenience
sample of agencies were
surveyed.
☐Other:
OMH Youth
Assessment of
Care
This survey assesses the
perception of care in youth
around the areas of:
appropriateness of care,
accessibility of services, cultural
sensitivity, medication use,
functioning/outcomes, and global
satisfaction.
2012 data is now
available.
D-13
Survey
instrument
Purpose
Use of sample
Frequency of data
collection/analysis
Date of last data
collection/analysis*
OMH Family
Assessment of
Care
This survey assesses the
perception of care among families
of youth in care around the areas
of: appropriateness, accessibility
of services, cultural sensitivity,
medication use, functioning/
outcomes, global satisfaction, and
social connectedness.
☐ 100%
☐Quarterly
2012 data is now
available.
☐ Representative sample
☒ Annually
☐ Stratified sample
☐Ad hoc
☒ Other: Families of
youth who received
treatment during a
specified time period from
a convenience sample of
agencies were surveyed.
☐Other
NYSOFA:
To collect statewide outcome data
Caregiver Services on caregiver’s experience and
Survey instrument satisfaction with providers.
based on
Performance
Outcome
Measurement
Project (POMP)
☐ 100%
☐Quarterly
☐ Representative sample
☐Annually
☒ Stratified sample
☒Ad hoc
☒ Other: The population
and sample was not
defined in terms of
Medicaid status and
therefore included
caregiver’s without regard
to any Medicaid status.
☐Other:
2008
D-14
Survey
instrument
Purpose
Use of sample
Frequency of data
collection/analysis
Date of last data
collection/analysis*
National Core
Indicators,
personal interview
protocol
OPWDD system tracking re:
proportion of individuals lacking
an integrated job in the
community, who desire one.
☐ 100%
☐Quarterly
2013 collections ends 9/30
☒ Representative sample
☒Annually
☐ Stratified sample
☐Ad hoc
☐ Other
☐Other:
☒ 100%
☒Quarterly
☐ Representative sample
☐Annually
☐ Stratified sample
☐Ad hoc
☐ Other
☐Other:
☒ 100%
☒Quarterly
☐ Representative sample
☐Annually
☐ Stratified sample
☐Ad hoc
☐ Other
☐Other:
N/A
N/A
New York Employment Services
System (NYESS).
OPWDD Tracking and Billing
System (TABS), service system
database to track (among other
things) residential movements
under de-institutionalization.
N/A – ‘live’ database,
monitored quarterly for
report out of targeted
growth in Competitive
Employment of people
with developmental
disabilities.
N/A – ‘live’ database,
monitored quarterly for
report out of Campus/ICF
targeted movements and
closures.
D-15
Survey
instrument
Purpose
Use of sample
Frequency of data
collection/analysis
Date of last data
collection/analysis*
N/A
eMedNY, Medicaid tracking
system.
☒ 100%
☒Quarterly
☐ Representative sample
☐Annually
☐ Stratified sample
☐Ad hoc
N/A – ‘live’ database,
monitored quarterly for
report out of targeted
enrollment growth in selfdirected services.
☐ Other
☐Other:
☐ 100%
☐Quarterly
☐ Representative sample
☐Annually
☐ Stratified sample
☐Ad hoc
☒ Other: Ongoing “three
point in time” collection
for those whose moves
from institutions were
augmented by MFP
☒Other:
Money Follows
the Person (MFP),
Quality of Life
Survey
(Mathematica)
Quality of life survey for those
transitioning from institutions.
Ongoing, collection
dependent on individual’s
discharge dates. Data last
compiled in June 2013.
* If data has not yet been collected and analyzed, please input the date when you expect them to be collected and analyzed.
D-16
3.2. Describe progress and anticipated challenges.
Describe progress toward implementing this measure:
NYS has compiled the list of outcomes data and sources for its programs and their populations
together with the frequency and last collection date (described above) and has also begun collecting a
single catalog of outcomes data used for its Medicaid populations.
Describe experienced or anticipated challenges to implementing this measure:
Historically NYS has approached outcomes data collection and related measures from a programmatic
rather than a population perspective. As such there are no interagency mechanisms to evaluate
whether a uniformity or common data set is feasible and, if so, what the effort to achieve such
commonality would be. Also, the UAS-NY is currently being implemented, so a critical mass of data
has not yet been collected. While the data will be available to providers as it is collected on an ad-hoc
basis, the new system currently lacks standard reports about these particular outcomes that providers
might easily access, interpret and use in the same manner.
Describe the State's plan to address the challenges described above:
In response to the BIP requirement, NYS has identified an interagency team for the compilation and
cataloging of outcomes data. This team will review the current compilation as well as any new
requirements in order to evaluate whether commonalities for populations can be achieved. As the
team identifies the measures which are captured in the UAS-NY, the system will be evolved to
include standardized reports for providers to access and interpret these measures. The standardized
reports can then be made available to providers serving other populations as the UAS-NY system is
expanded to include assessments for the I/DD and BH/MH populations. In addition, NYS will
evaluate adding additional features to the UAS-NY such as a Quality of Life survey.
D-17
Balancing Incentive Program
Protocol for Service Data (baseline calculation and subsequent reporting)
Appendix D.1: Protocol for Service Data
D.1-1
Balancing Incentive ProgramProtocol for Requesting Advances and Claiming
Balancing Incentive Program
Protocol for Service Data
(Baseline calculation and subsequent reporting)
August, 2013
D.1-2
Balancing Incentive Program
Protocol for Service Data (baseline calculation and subsequent reporting)
Table of Contents
1.
INTRODUCTION ....................................................................................................................................... 44
2.
REPORTING PROCESS AND CYCLES44
3.
THE CATEGORIES OF SERVICE AND DATA SOURCES45
4.
ADJUSTMENTS: OTHER DATA SOURCES, CALCULATIONS & METHODOLOGIES ............ 66
5.
4.1
PRIVATE DUTY NURSING EXPENDITURES NOT INCLUDED IN LINE 41 ......................................................... 66
4.2
“INSTITUTIONAL” AND “OTHER AMOUNTS” INCLUDED IN COMMUNITY LINE 18A - MLTC AND MCO’S. . 66
PLANNED IMPROVEMENTS ................................................................................................................. 66
D.1-3
Balancing Incentive Program
Protocol for Service Data (baseline calculation and subsequent reporting)
1. INTRODUCTION
The purpose of this document is to set forth a protocol and methodology for collecting
service data to calculate the baseline percentage of community long term services and
supports (LTSS’s) to total LTSS’s under the Balancing Incentive Program (BIP)
requirements.
The Balancing Incentive Program was authorized under Section 10202 of the Affordable
Care Act (ACA) and offers financial incentives to States to balance their LTSS systems
by increasing access to and expanding community services as an alternative to
institutional care.
New York State (NYS) was approved for BIP funding in March, 2013 in the amount of
2% of enhanced Federal Medical Assistance Percentage (FMAP) on expenditures for
certain long term services and supports beginning April 1, 2013 and ending September
30, 2015. The program requires States to “rebalance” their Medicaid LTSS expenditures
so the community portion is at least 50% of the total expenditures.
The Centers for Medicare and Medicaid Services (CMS) originally calculated States
community LTSS expenditure percentages using a public data source for the year ended
9/30/2009. CMS requires states to update that “baseline” calculation to the year just prior
to their approval in the program, which is year ended 3/31/2013 for NYS.
The BIP also requires States to use internal state data sources and describe methodologies
for the calculation. Finally, the BIP requires states to document the protocol and to report
an updated ratio every 6 months during the BIP period. The protocol must be updated
when necessary as well.
The scope of this document does not include the BIP protocol for requesting advances
and claiming (which is associated with the statewide “CMS 37” and “CMS 64”
submissions). However the data sources, categories of services, methodologies, and
calculations set forth in this protocol have been designed to align and mirror those used in
both the request for advance and claiming for BIP.
2. REPORTING PROCESS AND CYCLES
The process for collecting service data for calculating the percentage of community LTSS
for expenditures will align with the statewide Medicaid process except the BIP requests
and submissions:
•
will be accounted for separately and
•
will contain certain adjustments to comply with BIP requirements.
The cycle for reporting community LTSS ratios and protocol updates after the baseline
calculation is semi-annual with the first reporting period 4/1/2013-9/30/2013.
D.1-4
Balancing Incentive Program
Protocol for Service Data (Baseline Calculation)
3. THE CATEGORIES OF SERVICE AND DATA SOURCES
The categories of service defined for LTSS under the BIP align with definitions for
category lines in the statewide CMS 64 reporting system and are:
Community LTSS
Line 12 – Home Health Services
Line 18A – Medicaid Health Insurance Payments: Managed Care Organizations (MCO)
– new lines created for non-institutional Home and Community Based Services (HCBS)
Line 18B1 – Prepaid Ambulatory Health Plan – new lines created for non-institutional
HCBS
Line 18B2 – Prepaid Inpatient Health Plan – new lines created for non-institutional
HCBS
Line 19A – Home and Community-Based Services – Regular Payment (Waiver)
Line 19B – Home and Community-Based Services – State Plan 1915i Only Payment
Line 19C – Home and Community-Based Services – State Plan 1915j Only Payment
Line 19D – Community First Choice – State Plan 1915k
Line 22 – Programs Of All-Inclusive Care Elderly
Line 23A – Personal Care Services – Regular Payment
Line 23B – Personal Care Services – SDS 1915j
Line 24A – Targeted Case Management Services – Community Case-Management
Line 24B – Case Management State Wide
Line 40 – Rehabilitative Services (non-school-based) - Mental Health and Substance
Line 41 – Private Duty Nursing
Line 43 – Health Homes for Enrollees with Chronic Conditions
Institutional LTSS
Line 3B -- Nursing Facility Services – Supplemental Payments
Line 4A -- Intermediate Care Facility Services – Mentally Retarded: Public Providers
Line 4B -- Intermediate Care Facility Services – Mentally Retarded: Private Providers
Line 4C -- Intermediate Care Facility Services - Supplemental Payments
Line 2A -- Mental Health Facility Services – Regular Payments
Line 2B -- Mental Health Facility Services – DSH Adjustment Payments
D.1-5
Balancing Incentive Program
Protocol for Service Data (Baseline Calculation)
The primary data source used for CMS 64 claiming and the baseline calculation is the eMedNY claims processing system. The reports are generated via the Medicaid Data Mart
and the Management and Administrative Reporting subsystem (MARS).
4. ADJUSTMENTS: OTHER DATA SOURCES, CALCULATIONS &
METHODOLOGIES
So far, two circumstances have been identified for which adjustments to the amounts in
the statewide reporting classifications need to be made. These adjustments will be
reflected in a separate spreadsheet and involve the LTSS expenditure categories reported
and described in section 3 above for the purposes of calculating the baseline percentage.
4.1.
Private Duty Nursing expenditures not included in Line 41
The first circumstance involves a reclassification to include the “Private Duty Nursing”
category. It is currently included in the “Other Practitioners” category line on the CMS
64’s.
The primary data source used to identify the amount for private duty nursing is still the eMedNY claims processing system. However, the reports are generated by Salient©, an
analytical platform which happens to be constructed to capture expenditures on a date of
service basis. (MARS uses payment dates as a basis for capturing expenditures).
4.2.
“Institutional” and “Other Amounts” included in community Line 18A - MLTC and
MCO’s.
All capitation payments to managed care organizations are classified as community
expenditures in the statewide reporting system. These amounts need to be reduced for the
amounts which are other than long term care expenditures for BIP. They also need to be
reduced for the institutional portion and the institutional total needs to be increased by the
same amount.
These institutional and other amounts are not distinguished in capitation payments but are
able to be estimated using information available from the cost reports. The amounts for
these are distinguished and their ratio to the premium can be applied to reduce the
capitated payments in Line 18A. The institutional portion will be added to the
institutional total.
The results of the baseline calculation of the community LTSS percentage for the SFY
3/31/13 are attached at the end of this document.
5. PLANNED IMPROVEMENTS
This initial protocol will be improved after more work is done to understand or how to handle the
following areas:
•
Prepaid inpatient (HCBS vs. Institutional Amount)
•
Rehabilitative services (non-school based) mental health and substance
abuse
D.1-6
Balancing Incentive Program
Protocol for Service Data (Baseline Calculation)
•
Nursing facility supplemental payments
•
Prepaid ambulatory plans
It is anticipated the categories above will be researched further and the protocol will be revised to
reflect any changes which may be necessary in the next reporting period.
D.1-7
Balancing Incentive Program
Description
Community LTSS :
Line 12 – Home Health Services
Line 18A – Medicaid Health Insurance Payments: Managed Care
Organizations (MCO)
Line 18B1 – Prepaid Ambulatory Health Plan
Line 18B2 – Prepaid Inpatient Health Plan
Line 19A – Home and Community-Based Services – Regular Payment
(Waiver)
Line 19B – Home and Community-Based Services – State Plan 1915i
Only Payment
Line 19C – Home and Community-Based Services – State Plan 1915j
Only Payment
Line 19D – Community First Choice – State Plan 1915k
Line 22 – Programs Of All-Inclusive Care Elderly
Line 23A – Personal Care Services – Regular Payment
Line 23B – Personal Care Services – SDS 1915j
Protocol for Service Data (Baseline Calculation)
Total SFY 3/31/13
%age
Total SFY
3/31/14
%age
Total FFY
9/30/14
%age
Total SFY
3/31/15
%age
Total FFY
9/30/15
%age
2,347,090,954
139,659,366
5,857,953,986
262,609,745
2,258,745,846
591,100,027
Line 40 – Rehabilitative Services (non-school-based) - Mental Health
and Substance Use
Line 41 – Private Duty Nursing
5,679
Total Adjusted Community LTSS
Total FFY
9/30/13
1,309,022,118
Line 24A – Targeted Case Management Services – Community CaseManagement
Line 24B – Case Management State Wide
Line 43 – Health Homes for Enrollees with Chronic Conditions
%age
-
204,273,257
65,082,840
13,035,543,818
54.34%
Institutional LTSS:
Line 3A -- Nursing Facility Services – Regular Payments
Line 3B -- Nursing Facility Services – Supplemental Payments
6,860,495,268
-
Line 4A -- Intermediate Care Facility Services – Mentally Retarded:
Public Providers
Line 4B -- Intermediate Care Facility Services – Mentally Retarded:
Private Providers
Line 4C -- Intermediate Care Facility Services - Supplemental
Payments
Line 2A -- Mental Health Facility Services – Regular Payments
2,123,947,605
Line 2B -- Mental Health Facility Services – DSH Adjustment
Payments
Total Institutional LTSS per 64's
534,850,000
10,951,423,640
45.66%
Total Adjusted LTSS
23,986,967,458
100.0%
957,301,415
474,829,352
D.1-8
Appendix E.1: Description of Funding Source / Description of how State will use the enhanced funding
earned through the program
E.1-1
Activity
NYS
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
Ref. for
Notes
REBALANCE EXPENDITURES TO INCREASE COMMUNITY LTSS IN RELATION TO INSTITUTIONAL LTSS:
Insufficient
community
capacity
Increase OPWDD HCB Capacity (housing
and services) for transitions:
Develop an effective cross-systems crisis
prevention and response system utilizing
the nationally recognized START model,
initially in regions impacted by the
closure of an OPWDD institutional
program.
Establish ICF peer counseling network
Support costs associated with assistive
technologies and/or environmental
modifications to encourage/support
individuals to remain in their own homes
and/or live in less restrictive, more
integrated residential options.
Expand the availability of communitybased residential, day and support
service options.
Increase the number of people offered
the option to self-direct from 800 to
5,000.
25,630,000
12,430,000
13,200,000
I/DD
2,500,000
2,500,000
10,800,000
10,800,000
I/DD
I/DD
140,000,000
140,000,000
I/DD
2,830,000
2,830,000
I/DD
1
E.1-2
Activity
Increase OMH Capacity for transitions
into the community:
Create a pool to expand services for
individuals coming out of State PCs and
to expand capacity for 1915(i) services in
BHO Waiver application for plans to
rebalance by shifting inpatient care into
the community.
NYS
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
Ref. for
Notes
2
20,000,000
20,000,000
BH/MH
REBALANCE EXPENDITURES TO INCREASE COMMUNITY LTSS IN RELATION TO INSTITUTIONAL LTSS:
Transition up to 1,000 individuals in
Nursing Homes and Adult Homes to
community settings pursuant to
Olmstead Plan and a settlement
agreement.
Enhanced Community Supports Personalized Recovery Oriented Services
Enhancement
Development and implementation of a
self-directed care pilot for individuals
transitioning from Adult Homes and
Nursing Homes into the community
Transition capacity up to 150 children
from institutional settings into the
community
Expand OMH HCBS Waiver Slots to
facilitate further State inpatient
children's bed reductions
BH/MH
11,000,000
11,000,000
BH/MH
2,000,000
2,000,000
BH/MH
BH/MH
11,000,000
11,000,000
BH/MH
E.1-3
Activity
Transition up to 350 individuals residing
in State Psychiatric Centers (PCs) who
would be better served in community
settings with appropriate supports:
Enhanced Community Supports
(clinics, health homes plus, mobile
treatment, LTC supports) including
transitional Community Support Teams
led by RN’s and staffed with peers and
MHTA’s/CNA’s.
Train state-workforce in facilitating
transitions, managing medical problems
and providing personal care services
(CNA Program).
NYS
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
Ref. for
Notes
BH/MH
4,000,000
4,000,000
BH/MH
2,000,000
2,000,000
BH/MH
REBALANCE EXPENDITURES TO INCREASE COMMUNITY LTSS IN RELATION TO INSTITUTIONAL LTSS:
Create 24/7 crisis capacity establishing a
community based crisis stabilization
team which includes a professional
consultation capacity and the availability
of direct crisis support for OMH
individuals transitioning to supported
housing.
Increase Capacity (Housing and
Services) for transitions:
MFP’s TRAID and other projects in the
MFP protocol.
2,000,000
11,750,000
2,000,000
BH/MH
11,750,000
All
E.1-4
Activity
Establish additional housing support
services for units reserved for people
coming out of adult homes, nursing
homes, developmental centers and
psych units.
Create a fund for demonstrating
innovations. (Still Pending)
Implement CFCO to streamline service
silos and increase access to home and
community based service options.
Increase caregiver support services.
Engage and train discharge planners in
expanded community services and
supports for all facility types.
Provide training for OMH supported
housing and family care providers to
accommodate this population and access
long-term care supports.
Continue to build statewide capacity to
offer evidence based programs to
Medicaid adult population (CDSMP,
DSMP,DPP).
Use evidence based criteria to identify
those at risk for institutional
placements (UAS-NY CAP outcome:
individuals triggered for institutional
risk).
NYS
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
10,000,000
10,000,000
All
45,000,000
45,000,000
ABD
800,000
800,000
All
3,500,000
8,500,000
3,500,000
8,500,000
All
All
1,250,000
1,250,000
BH/MH
5,000,000
5,000,000
All
2,500,000
2,500,000
All
Ref. for
Notes
3
4
5
E.1-5
Activity
322,060,000
294,610,000
TOTAL FOR CAPACITY
LACK OF FINANCIAL INCENTIVES: for community placement (Still Pending)
Adjust Rates:
Expand PACE program in non-urban
areas.
Create a pool that MMC, FIDA, MLTC and
other MC entities can compete for by
meeting rebalancing targets.
Provide funding to support start-up costs
for DISCOs.
Enhance reimbursement for residential
and day services to enlist a sufficient pool
of providers to support campus based
transitions.
Enhance reimbursement for residential
services to enlist a sufficient pool of
providers to support non-campus based
transitions.
Enhance reimbursement for supported
employment programs to support those
leaving the education system.
Enhance reimbursement for Family Care
services to enlist additional providers of
this low-cost residential service provided
in the confines of a family home.
Provide funding to incentivize providers
NYS
Ref. for
Notes
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
27,450,000
9,870,000
9,870,000
ABD
50,000,000
50,000,000
All
6
18,000,000
18,000,000
I/DD
7
18,300,000
18,300,000
I/DD
8
15,700,000
15,700,000
I/DD
21
47,500,000
47,500,000
I/DD
9
18,900,000
18,900,000
I/DD
3,500,000
3,500,000
I/DD
10
E.1-6
Activity
NYS
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
Ref. for
Notes
to consolidate often duplicative
administrative functions.
LACK OF FINANCIAL INCENTIVES: for community placement (Still Pending)
Transition to a standardized
reimbursement methodology for Notfor-Profit-Operated Residential
Habilitation, Group Day Habilitation
and Intermediate Care Facilities
Services.
Transition individuals currently residing
in Skilled Nursing Facilities into more
appropriate, community-based
residential and day program options.
Enhanced reimbursement and/or
capacity for rehabilitative services in
community residences and apartment
treatment for up to 1,000 individuals
discharged from OMH State PCs, Nursing
Homes and Adult Homes
In-Reach and Assessment for OMH
population transitions:
TOTAL FOR FINANCIAL INCENTIVES
22,230,000
22,230,000
I/DD
11
2,060,000
2,060,000
I/DD
12
11,250,000
11,250,000
BH/MH
13
2,500,000
2,500,000
BH/MH
2
219,810,000
219,810,000
-
IMPROVE INFRASTRUCTURE FOR THE EFFICIENT PROVISION OF COMMUNITY LTSS ACROSS ALL POPULATIONS:
IMPLEMENT NWD/SEP: for consistent information and accessible entry points
E.1-7
Activity
Expand NY Connects statewide and add
features.
31,000,000
13,000,000
12,000,000
NYS
Ref. for
Notes
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
6,000,000
All
14
15
IMPLEMENT CORE STANDARDIZED ASSESSMENTS: for determining eligibility for community LTSS in a uniform
manner
Support robust usage and expand use
of UAS-NY:
Integrate OPWDD's Coordinated
Assessment System (CAS) with the UASNY. Implement.
Integrate and automate OMH
assessment with DOH and OPWDD
assessments in the UAS-NY. Implement.
Other UAS-NY evolution to include
features to meet BIP requirements and
support robust usage.
4,200,000
4,000,000
200,000
3,350,000
1,000,000
2,350,000
I/DD
BH/MH
8,000,000
8,000,000
ABD
IMPROVE CONFLICT FREE CASE MANAGEMENT:
Separate case management from fiscal
decisions, strengthen oversight and
implement administrative firewalls, use
of contractual terms and conditions.
2,000,000
2,000,000
All
48,550,000
28,000,000
14,550,000 6,000,000
TOTAL FOR INFRASTRUCTURE
MFP/BIP ADMINISTRATIVE RESOURCES: not sufficient to manage infrastructure improvements or reporting and
data collection across populations/agencies
MFP ADMINISTRATIVE RESOURCES: leverage for efficiency
E.1-8
Activity
Enhance MFP Administrative Budget
Implement evidenced-based criteria for
identifying candidates for successful
transitions.
3,000,000
160,000
1,000,000
NYS
2,000,000
Ref. for
Notes
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
16
160,000
All
All
660,000
All
17
BIP REPORTING AND DATA COLLECTION: systems not in place
Develop Final Work Plan (protocols) &
Quarterly Progress Reporting.
Quality Data protocol, reporting and
response:
Improve the overall quality of service
delivery through additional staff
resources, as well as enhancements to
information technology infrastructure.
Adopt practice guidelines for care
coordinators based on the Council on
Quality and Leadership (CQL) personal
outcome measures (POM).
Develop an Information Technology
infrastructure that will ultimately
improve care coordination through the
People First Waiver.
DOH/OMH responses for improving
quality after measuring.
660,000
18
10,000,000
10,000,000
I/DD
6,000,000
I/DD
23,300,000
23,300,000
I/DD
13,200,000
13,200,000
All
6,000,000
MFP/BIP ADMINISTRATIVE RESOURCES: not sufficient to manage infrastructure improvements or reporting and
data collection across populations/agencies
DEDICATED RESOURCES TO MANAGE STRUCTURAL IMPROVEMENTS: under BIP not in place
E.1-9
Activity
Develop a process to assure new
offerings and services meet documented
needs on a person by person basis.
Enhance service planning and case
management systems to include
electronic processes which capture new
data to support the right people are
getting the right services at the right time.
TOTAL FOR ADMINISTRATION
GRAND
TOTAL
Summary:
Capacity
Financial Incentives
Infrastructure
Administration
Grand Total
2,660,000
660,000
2,300,000
2,300,000
61,280,000
56,280,000
2,000,000
1,000,000
4,000,000
43,000,000
10,000,000
651,700,000
598,700,00
322,060,000
219,810,000
48,550,000
61,280,000
651,700,000
294,610,000 27,450,000
219,810,000
28,000,000 14,550,000
56,280,000
1,000,000
598,700,00
43,000,000
* Populations:
I/DD- Intellectually/Developmentally Disabled
BH/MH- Behavioral Health/Mental
Health
ABD- Aged, Blind, Physically Disabled
All- Any and All
NYS
Ref. for
Notes
Population*
BIP
Requirements
with Gaps and
Issues
Estimated Amount for 4/1/13 to 9/30/15
Total
BIP
MFP
All
19
All
20
6,000,000
4,000,000
10,000,000
-
E.1-10
Funding Table Notes
REBALANCE EXPENDITURES TO INCREASE COMMUNITY LTSS IN RELATION TO INSTITUTIONAL
LTSS:
NOTE 1: Line Item - Expand the availability of community-based residential, day and support service
options line item
NYS proposes to use BIP funds to provide “base funding” to increase the availability of lower-cost and more
integrated community program options, including funding for HCBS-compliant residential programs for
approximately 2,015 new OPWDD HCBS waiver enrollees during each year of the BIP grant period. These are
individuals who are newly entering the waiver from institutions and those that are "aging out" of both in- and
out-of-state private residential school programs to more appropriate settings in NYS. Specifically, BIP funds
will be used to support the initial year of waiver funding for new individuals with an assumed phase-in of nine
months. The phase-in is based on OPWDD recent budget experience.
Each year, OPWDD anticipates the services outlined below will be provided to individuals with BIP funding.
The numbers of individuals served are in parenthesis and are duplicated across services.
•
•
•
•
Day Habilitation (700),
Supported Employment (125),
Community Habilitation (505), Respite (505), and Service Coordination (2,015).
Residential Habilitation in certified settings (450 in first year based on institutional run-down and
other high-needs new populations).
The actual utilization of services for each year of BIP funding will vary based on the person-centered planning
process for individuals newly entering the waiver during the year.
Following the initial months of BIP funding, the services will be fully Medicaid-funded with 50% federal and
50% state share on a recurring basis thereafter. The State expects to sustain these services on a recurring
basis as a result of other system reform efforts, like on-going de-institutionalization and other efforts to
ensure individuals are receiving services that are appropriate to address their needs. As an example, the
average annual cost of serving an individual in a campus based facility is approximately $450,000. Transition
to self-directed community based services including residential and day will create an estimated savings of
$200,000, the state share of which can be reinvested to serve additional individuals in need of services.
Note 2: Activity Group - Increase OMH Capacity for transitions into the community (Still Pending)
OMH is developing several BIP supported initiatives to facilitate transitions into the community including:
•
Expansion of services for individuals coming out of institutional settings and capacity for 1915(i)
services to facilitate the shift from inpatient settings into community alternatives. As part of the
Medicaid Redesign Team, New York is preparing to integrate behavioral health care into
managed care to promote recovery in community settings and to improve outcomes while
reducing inpatient care, emergency room visits and readmissions. As New York prepares for the
design and implementation of Health and Recovery Plans (HARPs), BIP funds will be used to
E.1-11
support the transition to managed care by expanding resources for community based
alternatives, funding assessments and individualized plans for 1915(i) services and/or providing
incentive payments for individuals coming out of institutional settings.
Below are links to the initial MRT recommendations related to behavioral health reform and a
presentation to mental health services council.
http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrt_behavioral_health_reform_recommend.pdf
http://www.omh.ny.gov/omhweb/mh_services_council/2013/0607/behavioral_health_organizations_update.pdf
•
Expansion of in-reach teams and services for individuals coming out of adult homes and nursing
homes including intensive supports to restore, enhance or develop basic living skills to make the
community transition successful. Specifically, the BIP funds will be used to transition up to 1,000
individuals in nursing homes and adult homes by 1) expanding access to Personalized Recovery
Oriented Services (PROS) by providing resources for more intensive rehabilitation services and
off-site supports to allow individuals to learn and practice skills in community settings; 2)
developing a self-directed care demonstration program to be included in the 1115 waiver
1915(i)-like benefits package; and 3) establishing 6 in-reach teams to facilitate transitions from
adult homes into community settings.
•
Establishing a goal for the 10% reduction in the absolute number of long-stay patients within two
years.
•
Expansion of capacity for the Children’s Home and Community Based Services (HCBS) Waiver
program by adding 150 new slots statewide to facilitate a restructuring and downsizing of New
York’s children’s inpatient system. New York is developing Regional Centers of Excellence (RCEs)
to consolidate and reduce children’s inpatient beds across the State and enhance community
based services. The expansion of Children’s HCBS waiver capacity as an alternative to inpatient
care will help to facilitate the downsizing of State inpatient beds for children.
•
Expansion of Community Supports to facilitate a restructuring and downsizing of New York’s
adult inpatient system. New York is preparing to implement Regional Centers of Excellence
(RCEs) to consolidate and reduce adult inpatient beds across the State and enhance community
based services. BIP funds will be used for the development of: 1) mobile transition teams to
facilitate the recovery and successful transition to the community including the skills needed for
independent living such as using community resources, living independently, managing time,
managing medications, and being safe in the community; 2) crisis stabilization teams to prevent
an emergency room visit or rehospitalization; and 3) retraining for staff and community providers
to facilitate the transition from institutional settings into the community.
•
Below is a link to OMH’s initial Regional Centers of Excellence (RCE) plan.
http://www.omh.ny.gov/omhweb/excellence/rce/docs/rceplan.pdf
•
Expansion of capacity for rehabilitation services by enhancing reimbursement to facilitate the
transition from institutional settings into licensed transitional community residences providing a
wide range of Medicaid eligible services. The BIP funds will provide for crisis stabilization and
prevention to reduce rehospitalization, and enhanced supports required to transition individuals
E.1-12
from institutional settings including medication management, nutritional education, adaption
skills training and life coordination skills.
Note 3: Line Item – Create a fund for demonstrating innovations (Still Pending)
The Innovations Fund is envisioned as a way to make sure that stakeholders have a dynamic role in
implementing BIP in New York State. In addition, it will ensure that those providing vital community-based
services have the opportunity to address barriers they face in doing so in the least restrictive appropriate
setting. The Fund is intended to provide resources to implement capacity building projects that address
specific, identified barriers to community-based care across the full spectrum of disabilities. A Request for
Grant Applications will be issued that requires applicants to 1) identify the barrier to home and community
based care they seek to address; 2) describe the proposed innovation and its expected impact on rebalancing
in New York State; 3) estimate the anticipated cost of the proposal, including a cost/beneficiary analysis; and
4) provide a statement as to whether and how the project will be sustained in the future. Grantees will have
to demonstrate the effectiveness of their funded innovation in mitigating the barrier identified and meeting
the needs of the individuals served.
Applications will be reviewed by an internal interagency workgroup based on criteria released with the
application including cost effectiveness, the number of people reached with the innovation, the impact on
New York's rebalancing efforts, the innovation's likelihood of addressing the barrier to community based care
across the entire disability spectrum and a review of the grantees' past efforts, if any. Innovation Fund
proceeds will be awarded on a competitive basis.
Individuals who are to be assisted by the innovation will be Medicaid-eligible and assessed as needing an
institutional level of care. They will be transitioning to the community from institutionally based care or be at
risk for institutional placement. The projects funded through the BIP Innovation Fund must meet the BIP
requirements for use of funds.
NYS’ intent is to issue a Request for Grant Applications early in 2014 in order to give organizations awarded
funding at least 18 months in order to demonstrate the effectiveness of their projects as all funding needs to
be expended by September 30, 2015.
Note 4: Line Item – Increase caregiver support services (Still Pending)
Background: New York has undertaken work within a federal grant initiative focused on caregiving and
respite issues for all payers and for individuals across the age and disability spectrums, called the Lifespan
Respite Care Program initiative. A problem area that has been identified is the need to address identified
gaps and unmet respite needs of family caregivers across the lifespan. The lack of caregiver support and
respite often leads to caregiver burnout, which, in turn, may lead to nursing home placement. It also can
substantially affect the workplace, where caregivers often try to juggle their work responsibilities with their
caregiving responsibilities.
BIP funds would be used to expand availability of caregiver support and respite care to caregivers of Medicaid
beneficiaries/eligibles statewide that meet the target criteria.
E.1-13
Target Criteria: Caregivers of individuals with a diagnosed cognitive impairment (e.g., Alzheimer’s disease,
chronic diseases), caregivers of older adults, frail individuals, and persons of all ages with disabilities
(physical, functional, behavioral, etc.). This information would be available from the care recipient's
standardized assessment.
Geographic Focus/Numbers Served: This would be available statewide and based on need.
Types of Services: The service package would be based on the assessment of the care recipient and identified
need for services. These services would be used as respite for the caregiver, as well as training and support
to assist caregivers in their caring role:
• Adult day services – social adult day services (SADS) and Alzheimer’s Disease/dementia-specific day
services;
• Consumer-directed respite (capped);
• Overnight respite, including a temporary overnight stay in an adult care facility, nursing home, or
other setting;
• Caregiver services including support groups, counseling, education, and training programs to assist
caregivers in sustaining their role.
Example – a caregiver could receive one day per week of SADS for the care recipient for one year, 7
overnights per year, and 6 hours per month of caregiver supports and training (cost is expected to be an
average of $2500 per caregiver/year).
Note 5: Line Item - Continue to build statewide capacity to offer evidence based programs to
Medicaid adult population (CDSMP, DSMP, DPP) (Still Pending)
BIP will enable New York State to further develop capacity to offer several evidence based health promotions
programs to approximately 5 percent of Medicaid adult population with chronic diseases in the community
(approximately 30,000 persons). The specific evidence based programs include the Chronic Disease SelfManagement Program (CDSMP) and Diabetes Self-Management Program (DSMP) developed by Stanford
University, as well as the National Diabetes Prevention Program (NDPP) developed by the Centers for Disease
Control and Prevention. CDSMP and DSMP, which targets individuals with any type of chronic condition, such
as diabetes, pre-diabetes, arthritis, chronic pain, anxiety, cardiovascular disease and high blood pressure,
have helped individuals learn how to manage their conditions and been proven effective in yielding positive
outcomes for participants, with participants reporting improvements in symptom management, physical
activity, their ability to actively participate in their health care decisions, along with reductions in hospital
stays. NDPP, which helps individuals who are considered at risk for diabetes make lifestyle changes, has
helped reduce the risk of developing type 2 diabetes by 58 percent in people at high risk for diabetes.
Statewide Infrastructure Service: The New York State Office for Aging (NYSOFA) has been partnering with the
New York State Department of Health (NYSDOH), and the Quality and Technical Assistance Center at the
University at Albany (QTAC) to embed Evidence Based Interventions, including CDSMP and DSMP, into New
York State's health and long-term services and supports system. Although there is currently an existing
infrastructure for these evidence-based programs in New York which is supported in part by the US
Administration for Community Living and Centers for Disease Control and Prevention, the funds requested
through BIP would allow for increased delivery and reach of the CDSMP, DSMP and NDPP programs to
E.1-14
Medicaid recipients, additional training, and technical assistance to expand the reach of the programs
beyond the 30 percent of the State that is currently being served.
LACK OF FINANCIAL INCENTIVES: for community placement
Note 6: Line Item – Create a pool that MMC, FIDA, MLTC and other MC entities can compete for by
meeting rebalancing targets (Still Pending)
New York State intends to spend a portion of its BIP awards on rate enhancements to ensure an adequate
supply of qualified providers are available to serve individuals in home and community-based settings across
the state. A portion of those funds will be placed in a pool for which managed care entities serving
individuals from across the disability spectrum may compete for a temporary rate enhancement (see below).
This project is still in progress, but the State intends to work with stakeholders to establish criteria upon
which points may be assigned to plans to establish a ranked list. These criteria will include a statistically
significant decrease in the plan's percentage of members receiving long term services and supports in an
institutional setting, a statistically significant increase in the percentage of the plan's membership receiving
LTSS in qualified home and community based settings, satisfactory performance on a set of yet-to-be
determined quality measures that includes consumer satisfaction, and satisfactory performance on yet to be
determined measures of health outcomes. Plan members who are transitioned to the community must
remain there for at least six months for the plan to receive half of their award and at least a year to receive
the remainder. Criteria other than transitioning individuals out of institutional settings may be added to
rebalancing targets such as successful placement in competitive employment. Points awarded to plans based
on the approved criteria would result in a ranking of participating plans. A set percentage of plans would be
eligible for temporary rate increases based on their performance (i.e. rank).
The first year of the BIP implementation will serve as a baseline for all measures. There would be criteria
established for plans to be allowed to participate in the competition such as the time they have been
operational to ensure that there is a sufficient track record upon which to base performance.
The following information is in response to CMS NY Balancing Incentive Program Rate Questions
dated 12/5/2013 – Question A.
1. The existing managed care rate methodology would be unaffected as pool funds would be an addon to the current rate. Whatever portion of the funds a plan receives from the pool will be
allocated back to the plan and promulgated through a temporary rate increase. Any temporary
enhanced rate would be reviewed by DOH and our Actuary, Mercer, to ensure it is actuarially
sound and falls within appropriate rate ranges.
2. The current MLTC risk adjusted rates are based on functional and clinical need. The risk
adjustment methodology recognizes higher need individuals and provides higher reimbursement.
There is also an eligibility requirement that individuals must meet a nursing home level of care in
place. Current MLTC mandatory transition rates reflect community and SNF placement costs.
Current premiums reflect community based placements with costs that exceed SNF costs. FIDA
rate development is based on the MLTC premium methodologies therefore the same financial
incentives built into MLTC will exist in FIDA premiums. As for MMC, SNF custodial care is
E.1-15
currently carved out of rates and paid through FFS. Only rehabilitation stays are reimbursed
through the managed care rate. Thus, incentives to encourage community-based placements are
not currently necessary.
3. New York State would like to use the pool to incentivize plans to think about ways to maximize
quality in the provision of long terms services and supports in community based settings as they
are developing their business model. By establishing a pool that may recur in future years, we
hope to incentivize managed care plans across disabilities and geography to use any proceeds
from these efforts to reinvest in tools and techniques that help individuals defer institutional care
or successfully transfer from institutional to community based settings. Through its participation
in BIP, New York hopes to make placement in home and community based settings the default
for any individual that wants to remain in their home/community. This pool will help us reach
that goal and ensure that in our transition to managed care, plans that focus on quality LTSS in
community-based rather than institutional settings serve as beacons to those in need of such
services, as well as other plans. Utilizing a pool rather than modifying existing rate-setting
methodologies allows the necessary flexibility to provide varying degrees of payment to plans
based on distinct conditions that will required.
4. The incentive will address both avoiding new SNF placements as well as moving current SNF
residents to the community. Points toward rankings will be awarded both for deferring
institutional placement and for transitioning individuals from institutional settings to those that
are community based. New York State is currently deciding between developing or identifying
indicators of when a plan has deferred an individual from being placed in an institutional setting
or simply using a measure such as a UAS or CAS score that would indicate an institutional LOC
where that individual is served in the community and placing a higher weight on the percentage of
long term care members transitioned to community based settings.
5. The following table provides a detailed timeline for the incentive pool (in answer to questions A5
and A6 on CMS NY Balancing Incentive Program Rate Questions):
Task
Agency Date
Notes
Draft protocol for Pool
DOH
1/2/142/14/14
Including organizational
qualifiers/disqualifiers, definitions of
success, measurement criteria, data
sources, measurement cycles,
evaluation methodology,
reimbursement/disbursement
mechanism, etc.
Approved protocol for Pool
DOH
2/15/14- Including all necessary approvals
2/28/14
Developing materials and
coordinating stakeholder
DOH
2/1/14-
Identify interested parties, planning,
E.1-16
Task
Agency Date
engagement
Stakeholder Engagement
DOH
Notes
2/28/14
etc.
3/1/14-
Webinars, meetings, etc.
3/31/14
Approved Revised Protocol
DOH
4/1/144/15/14
Implementation planning
DOH
3/1/143/31/14
Implementation
DOH
4/1/149/30/14
Measurement and Quarterly
award cycles begin
All
10/1/14- 4 Quarterly reporting cycles
9/30/15
New York will establish a workgroup that includes stakeholders to determine additional measures
that reflect the robust nature of community based placement and integration such as length of time
the individual remains served in the community (minimum of 6 months will be required for
transitioned individuals); realization of individual goals such as competitive employment or
participation in community activities; and consumer satisfaction with community based services
and supports. New York’s participation in the Community First Choice Option, if approved by
CMS, will require measurement of these types of indicators and will facilitate their use in ranking
plans for rewards under the rate pool.
Note 7: Line Item – Provide funding to support start-up costs for DISCOs (Still Pending)
As part of its initiative to provide care management for all, NYS is working with CMS to develop a specialized
managed care program that will transform the way that care is organized and delivered across the continuum
of service needs for New Yorkers with Developmental Disabilities. These new, managed care organizations
will meet existing DOH Article 44 (DOH) licensure requirements for a certificate of authority and must also be
controlled by organizations that have a history of specialized service provision for individuals with intellectual
and developmental disabilities. As MCOs, these new entities must meet all existing managed care
requirements for 1) network development and management; 2) care coordination, quality improvement and
utilization management; 3) clinical information systems; and 4) data analytics. Given the limited experience
across the nation in serving individuals with Developmental Disabilities using a managed care model, entities
preparing to coordinate care for this population are uniquely challenged in the area of quality improvement
E.1-17
and performance measurement. Specifically, a national standard for measuring the effectiveness of care
coordination has not yet been established and organizations in NYS readying to serve individuals with
developmental disabilities have made considerable investments into developing this new model.
Considering the initial startup costs of establishing managed care capacity and given the unique features of
operating managed care for this specialized population, OWPDD is proposing to use these BIP resources to
establish a pool of funding from which grants could be awarded to potential plans to continue the
momentum and position itself, the State and its provider network to successfully achieve the goal of fully
integrated managed care.
NYS proposes that a matching grant pool be established that would allow not-for-profit entities that are
applying to become specialized managed care entities to apply for support with the adoption and
implementation of specialized Electronic Health Records (EHR) that provide for:
•
•
•
Integration of care among network providers, including community-based providers of specialized,
developmental disability services,
Care coordination capabilities, and
Implementation and effective utilization of an electronic health record by community-based network
providers.
Matching grant funds could not be used to meet contingent reserve and escrow requirements for DISCO
applicants.
Grant Awardees’ Selection
NYS is modeling the DISCO start-up grant activities after successful grant programs that have been
implemented in the past through Healthcare Efficiency and Affordability Law (HEAL) grants and
through start-up grants specialized managed care programs for people with HIV/AIDS. Grant
applicants will be selected on the basis of the successful completion of the initial phase of the
Certificate of Authority (COA) process to operate a DISCO. The initial phase of the COA review
process will be conducted jointly by the Department of Health and OPWDD and will ensure that the
applicant can successfully meets the New York State Public Health law (NYSPHL) Article 44
requirements in the following areas:
o
Organizational Structure – Review of detailed description of DISCO organizational structure,
organizational chart, Certificate of Incorporation and Bylaws.
o
Management of the DISCO – Review of management staff including positions budgeted but
not yet filled. The applicant provides a list of names addresses and official positions for Chief
Executive Officer (CEO), Medical Director, governing body and all management staff. The
applicant also identifies any delegated authority, and, if authority is delegated to contractors,
identifies the contractors. For certain functions, the contract itself must be reviewed by the
state for regulatory compliance.
o
Character and Competence – Comprehensive review of the licensure, qualifications and
background of the Medical Director, CEO, incorporators, stockholders, members, and each
member of governing body of DISCO.
o
Governing Board – Review of the role and responsibility of governing board. The
E.1-18
Bylaws of the governing board are also reviewed if these duties are not specified in the
corporate bylaws. The Board’s engagement with individuals served by the DISCO and
opportunities for these individuals to provide meaningful input are also reviewed.
o
Service Area – Identification of counties to be served and the rationale for choosing service
area.
o
Enrollment Projections and Target Population and the basis for projections. Note that
qualified individuals of all ages living in the area served by the DISCO will be eligible to enroll
in the DISCO, with the authorization of OPWDD. An individual will qualify for enrollment, if
he or she has a developmental disability, meets ICF/IID (Individual with Intellectual Disability)
level of care and is Medicaid-enrolled. This includes those enrolled in both Medicaid and
Medicare.
o
Finance – The State will review a description of the DISCO’s mechanism to maximize
reimbursement from Medicare and other benefits and the DISCO’s systems for securing and
integrating any potential sources of funding for services provided by or through DISCO,
including funding available under:
Supplemental Security Income (SSI) program
Medicare
Medicaid
Description of systems to process payment for services
The applicant must also include the following:
•
•
•
•
•
Revenue & Expense Statement
Pro-forma Balance Sheet
Source of initial capitalization
Proposed loan document if a subordinated loan
Describe arrangements to share financial risk, if appropriate
The second phase of the COA review process is detailed review of DISCO policy and operating
procedures; provider contracts; provider network adequacy; notices; and ultimately the preparation
for onsite review. The State expects that applicants that successfully complete the initial phase of
the COA process will ultimately be issued a COA upon completion of the entire review process.
Costs eligible for Grant Funding
The intent of the grant award is that all successful applicants will receive a matching grant award
based on a review of the applicant’s need and approval of a start-up budget that identifies
expenditure items that are available. Grant awards are contingent upon availability of BIP funds.
Grant funds may support four cost categories for pre-operational/start-up costs:
•
Management Information System Development (Potential eligible costs include salary for
Management Information system (MIS) support, Reporting/Data Maintenance, Applications,
Network Support, Helpdesk; and Non-Salary items such as file server/PC software, Personal
Computers)
E.1-19
•
•
•
Management Staff (Potential eligible costs include pre-operational costs for enrollment,
claims, member services, finance and management staff)
Provider Network Development (Salary and non-salary costs associated with credentialing,
on-site review, and clerical functions)
Establishment of Clinical Linkages (Potential eligible costs include salary and non-salary costs
during pre-operational period for pre-certification/authorization functions, case
management, referrals, Medical Director, Provider Liaison)
EHR that are approvable and the schedule for developing these capabilities for the not-for-profits
The types of MIS funding categories eligible for the grant awards are described above. DISCOs will be
expected to have available or have a plan for obtaining a full electronic record system that integrates
all services on a single platform, with the following features:
•
•
•
•
•
DISCOs must use an EHR that is federally certified as meeting meaningful use standards.
Requiring this certification guarantees that the EHR addresses federal and NY State
interoperability standards, HIPAA security requirements, consumer portals and core health
care standards that are now the norm for EHRs under federal health care reform.
The proposed EHRs must reflect customizations that reflect the holistic care coordination
requirements for individuals with developmental disabilities (e.g.; an electronic service plan
for the individual that links to the assessment and actual delivery of service, integration with
OPWDD systems, appropriate monitoring systems, etc.)
In addition to meeting government interoperability standards, the DISCOs EHRs must provide
a web portal for direct entry of service data by not-for-profit network providers that lack
EHRs capable of electronically exchanging data.
Program planning must include Personal Outcome Measures based on OPWDD guidance with
corresponding outcomes set by the member and his/her circle of support that are identified
in the electronic service plan.
Ability for alerts to be shared between network providers and the care coordinator
In keeping with information system policy for NYS, DISCO applicants must demonstrate how the
organization will come into compliance with the current version of the Statewide Policy Guidance,
which includes common information policies, standards and technical approaches governing health
information exchange. It is expected that all successful DISCO applicants will come into compliance
with these guidelines within 18 months of becoming operational. The guidance can be found at:
http://www.health.ny.gov/technology/statewide_policy_guidance.htm
Available Grant Amounts
Current plans for the grant award is that the applicant must demonstrate that the organization will
expend ¼ of the cost for eligible expenses, and grant awards may meet the remaining ¾ of the
eligible expenses. The state intends to issue awards not to exceed $1.5 million. At this time, OPWDD
expects that payment of the grant awards will occur in two phases. The first payment will be issued
upon the successful completion of the initial phase of the COA review. The remaining grant award
will be withheld subject to issuance of the COA.
E.1-20
Note 8: Line Items – Enhance reimbursement for residential and day services to establish a
sufficient pool of providers to support campus based transitions AND Enhance reimbursement for
residential and day services to establish a sufficient pool of providers to support non-campus based
transitions (Still Pending)
As OPWDD continues with its efforts to reduce its State-operated campus-based institutional programs and
transition the individuals to community-based settings, OPWDD is expanding the number of individuals with
high-needs who are served in more integrated, community-based settings. Particularly at the point of
transition, OPWDD anticipates that these individuals will need enhanced direct care staff and clinical
supervision above what currently is the norm for community-based programs. It is OPWDD’s intention to
provide a specialized level of care in order to incentivize qualified not-for-profit providers to serve these
individuals and contribute to NYS’s transformation goal of deinstitutionalization. These payments will be paid
on an interim basis with BIP funds, but will ultimately be incorporated into the transformational rate
methodologies upon completion of an analysis of the actual cost of providing services to these individuals in
the community, and inclusion of an acuity factor within the methodology itself.
Please note, for individuals who are newly entering the OPWDD HCBS Waiver and are leaving institutional
settings, this supplemental funding will be provided in addition to the “base funding” described in our
response to the CMS question related to BIP funding of community-based services.
The ICF Transition Plan shared with CMS on July 30, 2013 displays the split between state and private
provider census numbers. There are about 6,300 individuals served in non-campus-based ICFs, which are
operated by both the State and OPWDD’s network of not-for-profit providers; the vast majority of the
individuals served in this setting (nearly 5,700) are served in not-for-profit provider ICF programs.
OPWDD anticipates that the initial transition step for many of the individuals moving from both campus- and
non-campus-based institutional ICF programs will include residential, day and other support services in
programs managed by not-for-profit providers. Many of these individuals will be placed in MFP-qualifying
residences and meet home and community based standards upon transition. OPWDD has identified OPWDD
staff who are serving as MFP liaisons in every region of the State and continue to look at each individual and
determine whether he or she could be successfully placed in an MFP-qualifying residential option.
In terms of the proposed changes to the payment levels themselves, it costs, on average, approximately
$130,000 per year to serve an individual in the community (Residential Habilitation and Day Habilitation)
through the HCBS Waiver. To ensure providers have sufficient funding levels to appropriately serve these
individuals, OPWDD anticipates enhanced payment levels of a total of approximately $200,000 annually for
both the base and supplemental funding for this cohort (inclusive of residential and day programming) based
on an historical cost analysis. Even at these enhanced levels, the costs to serve these individuals is roughly
half of the cost of serving an individual in an OPWDD-operated, campus-based ICF program.
Note 9: Line Item – Enhance reimbursement for supported employment programs to support those
leaving the education system (Still Pending)
OPWDD supported employment services are completely aligned with the guidance in the CMS Informational
Bulletin. The design of the new Pathway to Employment service is modeled on the Career Planning service
within the CMS Bulletin. In addition, the supported employment service definition within the HCBS waiver is
E.1-21
being revised to be consistent with the CMS Bulletin. The new Pathway to Employment service would enable
people with developmental disabilities who are currently receiving day habilitation, prevocational or
workshop services, or youth exiting high school to successfully transition to integrated community
employment earning at or above minimum wage. BIP funding would be used to develop curriculum and train
providers on how to deliver the Pathway to Employment Service. BIP funding would also be used to offset
some of the initial increased cost associated with transitioning people from traditional day services to
employment. Providers will have additional cost associated with the job development and job coaching
services that will be needed to assist people in developing pre-employment skills, assessing employment
interests, developing resumes and going on interviews, learning job duties and maintaining job performance.
Note 10: Line Item – Provide funding to incentivize providers to consolidate often duplicative
administrative functions (Still Pending)
OPWDD is currently hosting a transformation work group focused on exploring and making recommendations
related to promoting improved provider efficiency and innovation. A subcommittee focused on provider
collaborations, consolidations and innovations is conducting an inventory of the variety of
options/possibilities for shared administrative services such as payroll, human resources, billing, insurance
etc. That subcommittee is also exploring options for provider agencies to partner through consolidations and
strategic alliances for shared efficiencies and will identify pros and cons and best practices. By consolidating
administrative functions that are common to all providers, providers can achieve better value in these
functions while retaining their focus on service delivery.
The findings and recommendations of this subcommittee and work group will inform the establishment of a
technical assistance resource that will be available to support non-profit service providers in activities related
to the transition to managed care. Providers may apply for funding support for innovation initiatives that will
result in more efficient, streamlined administrative functions that support their participation in DISCO(s)’
provider networks. Specifically, the funding will be available to support technical assistance (TA), direct onetime infrastructure costs, and related operations mapping and policy development. Examples of fundable
projects include underwriting technical assistance to nurture promising strategic restructuring projects
involving existing, or potential, partnerships between two or more organizations. TA support will range from
$10,000 - $40,000, depending on the scope of the proposed project and where it falls along the planning
continuum—pre-planning to full implementation. Projects at all stages of development will be considered,
from pre-planning and feasibility studies to implementation of a detailed restructuring plan.
OPWDD is working with DOH to make the necessary changes to eMedNY to track individuals who leave
institutional settings and whose services are eligible for reimbursement with the enhanced fees. OPWDD is
working with the DOH on a systems development request that will establish specific rate codes for these
enhanced fees. Staff is also developing a proposal for pre-payment system edits that will allow the use of the
enhanced payment rate codes only for qualified individuals. Qualified individuals will be identified in the
payment system with coding that is established by OPWDD and is assigned based on the person’s former
residence in a qualified institutional setting. The development of pre-payment edits is more challenging, and
has a lengthier development timeline than the establishment of new rate codes. To ensure accuracy of
payments prior to the implementation of pre-payment edits, OPWDD staff will monitor eMedNY payment
data to ensure that the use of these specialized rate codes are limited to individuals who qualify based on
their former institutional status. The State recognizes that BIP funds must ultimately support the costs of
these fees and will use BIP funds to reimburse the federal and state shares of Medicaid, so that BIP ultimately
E.1-22
supports the gross value of the claim, or direct charge BIP in the first instance. Individuals who are leaving
highly structured institutional settings such as campuses and skilled nursing facilities will need enhanced
supports beyond those which are typically provided in existing waiver program services. This level of support
will be needed for a period of time in order to ensure a successful transition.
Note 11: Line Item – Transition to a standardize reimbursement methodology for Residential
Habilitation and Group Day Habilitation (Still Pending)
OPWDD identified several areas of expenditure related to the initial development of and migration to the
new transformational rate methodology for its existing array of Medicaid services. Those expenditure areas
include:
•
•
•
•
Approximately $6.8 million over the 30-month period to support costs to identify and refine the
appropriate methodology to support the initial phase of services (ICFs, Residential Habilitation and
Day Habilitation), as well as assessing the remaining Waiver services as to whether more appropriate
and rational methodologies should be employed; the corresponding software and infrastructure
costs to roll-out the new methodologies; and need to train staff on the methodologies.
Nearly $1.8 million associated with enhancements to audit functionality, including contracts and
software associated with financial integrity audits, and the development of forensic audit capacity
within OPWDD.
More than $0.7 million to support “People First Waiver” compliance and training initiatives, including
enhancing OPWDD’s capacity to provide administrative oversight of the Waiver.
Some $0.2 million to support a staffing contract to address increased billing questions and denial
edits associated with OPWDD fee-for-service rate codes and other Medicaid billings as individuals
change services. Billing problems have previously impacted OPWDD’s ability to expand services, as
well as provider willingness to begin new services.
Note 12: Line Item – Transition individuals currently residing in Skilled Nursing Facilities into more
appropriate, community-based residential and day program options (Still Pending)
OPWDD would propose to provide similar levels of enhanced funding to not-for-profit providers opting to
serve individuals with developmental disabilities transitioning from Skilled Nursing Facilities to more
integrated community service options. These funding levels would be commensurate with those discussed
earlier for individuals transitioning from ICF programs –supplemental funding. As discussed earlier,
approximately $130,000 (all shares) per year is required to serve an average individual in the community
certified residential setting (Residential Habilitation and Day Habilitation) through the HCBS Waiver. To
ensure providers have sufficient funding levels to appropriately serve these individuals who meet a SNF level
of care, OPWDD anticipates enhanced payment levels of a total of approximately $200,000 annually for both
the base and supplemental funding for this cohort (inclusive of residential and day programming) based on
an historical cost analysis.
These payments will be paid on an interim basis with BIP funds, but will ultimately be incorporated into the
transformational rate methodologies upon completion of an analysis of the actual cost of providing services
to these former SNF residents in the community, and inclusion of an acuity factor within the methodology
itself.
E.1-23
OPWDD has identified regional MFP Coordinators who will be responsible for assessing individuals and
making the determination if they can be successfully served by an MFP-qualifying residential opportunity.
OPWDD is steadfastly endeavoring to keep people out of nursing homes and to get individuals currently in
residence out as soon as practicable. OPWDD has requested that provider agencies work closely with the
agency to find an alternative residential placement for anyone who is unable to return home following a
hospitalization. Currently, OPWDD staff is working on a person-by-person basis with local placement/intake
coordinators, along with voluntary agency service coordinators, with those individuals who have a
designation as being appropriate for a residential option. In the future, OPWDD plans to develop a report
showing the number of individuals awaiting placement with any given region. It is assumed that some
percentage of SNF residents with developmental disabilities will be placed into MFP-qualifying residential
options; however, MFP monies will not be used to support the costs of these direct services, in accordance
with the State’s recently amended MFP Operating Protocol.
The concept enhanced funding is similar to that of the underlying premise to support individuals transitioning
from campus-based institutional programs – provide enhanced reimbursement to incentivize providers to
support individuals transitioning from skilled nursing facilities to the community in order to ensure that
appropriate levels of supports are available to facilitate success. The fees will also provide for the
development of supports that are tailored to the individual needs and choices of each person leaving a skilled
nursing facility and will encourage supports that result in opportunities for individuals to return to their home
if they choose and to direct the supports they need to ensure the success of the transition. These fees reflect
the fact that all individuals meet the specialized level of care requirements for a nursing home and vary based
on the region in which the individual has chosen to reside (to reflect cost differences). The proposed fees for
individuals leaving skilled nursing facilities – which will be wholly supported with BIP funds – are as follows:
Note 13: Line Item – Enhanced reimbursement and/or capacity for rehabilitative services in
community residences and apartment treatment for up to 1,000 individuals discharged from OMH
State PCs, Nursing Homes and Adult Homes (Still Pending)
Enhanced reimbursement will be provided for the expansion of Medicaid eligible rehabilitation services to
facilitate the movement of patients from institutional settings to community settings. Specifically, the intent
is to enhance reimbursement to a provider that enrolls a patient being discharged from an Adult Home,
Nursing Home or a State Psychiatric Center in their Community Residence program since these individuals
require higher levels of rehabilitation services to facilitate the transition into the community. A total of
$11,250,000 has been made available for this project.
Currently providers receive a single Medicaid rate that covers all rehabilitative services provided. Persons
transitioning out of institutional settings have acute intensive rehabilitative needs associated with
transitioning into a community setting. The enhanced reimbursement would allow providers to have
additional funding available to pay for Medicaid eligible rehabilitative services for the acute and greater
needs of persons transitioning out of institutions.
E.1-24
Medicaid Eligible Services to be provided to eligible persons transitioning
The enhanced reimbursement will provide an increased number and duration of rehabilitation services being
provided for wide range of needs in an intensive and comprehensive manner to individuals coming from the
institutional settings for the purpose of facilitating their transition into independent living within the
community in safe and affordable housing. Rehabilitation services eligible for enhanced reimbursement
include the following:
•
•
•
•
•
•
•
•
•
Assertiveness/Self Advocacy Training which is designed to promote the individuals’ ability to assess
his or her needs to make a life status change and to increase self-awareness about his or her values
and preferences.
Community Integration Services/Resource Development designed to help individuals to identify skills
and community supports necessary for specific environments, to assess their skill strengths and
deficits in relationship to environmental demands, to assess resources available to help the
individuals, and to develop a natural support system by accessing social, educational, and
recreational opportunities.
Daily Living Skills which focus on the acquisition of skills and capabilities to maintain primary activities
of daily life- Health Services to maximize independence in personal health care by increasing the
individual’s awareness of his / her physical health status and the resources required to maintain
physical health, including regular medical and dental appointments, basic first aid skill and basic
knowledge of proper nutritional habits and family planning.
Medication Management and Training regarding the storage, monitoring, recordkeeping and
supervision associated with the self-administration of medication.
Parenting Training intended to promote positive family functioning and enable residents to assume
parenting responsibilities.
Rehabilitative Counseling includes assisting the individual in clarifying future directions and the
potential to achieve rehabilitation goals, identifying and specifying behaviors that impede goal
setting, improving awareness of the influence of environmental stress, and helping the individual to
generalize newly learned behaviors to housing and other situations outside the program structure.
Skill Development Services assist clients to gain and utilize the skills necessary to undertake
employment or pursue educational opportunities.
Socialization is intended to diminish tendencies toward isolation and withdrawal by assisting
residents in the acquisition or development of social and interpersonal skills.
Substance Abuse Services provided to increase the individual’s awareness of alcohol and substance
abuse and reduction or elimination of its use.-Symptom Management which are intended to achieve
a maximum reduction of psychiatric symptoms and increased functioning.
In addition, the service of Peer Support and Bridger will enhance the already existing Rehabilitation
Restorative Services that are described above. Peers are determined by a clinical professional to be capable
of assisting recipients of mental health care in the recovery process; activities include assisting consumers
with writing advance directives, scheduling appointments with providers, teaching wellness self-management
skills, and bridging individuals from Congregate Care Settings to the more independent, less restrictive
housing settings of Supported Housing.
E.1-25
Identifying Eligible Individuals/Providers
Using the NYS Office of Mental Health’s (NYS OMH) Children and Adult Integrated Reporting System (CAIRS)
Residential Program Indicators Report, OMH will identify patients originating from State Psychiatric Centers,
Adult Homes and Nursing Homes that were enrolled in Community Residence apartment or licensed,
Medicaid eligible congregate programs. OMH will provide a 30% enhancement to the standard Community
Residence rate for the first year and 15% enhancement during the second year.
Operationalizing Enhanced Reimbursement
On a quarterly basis, the NYS OMH will calculate the enhanced reimbursement to eligible providers based on
the individuals served in the previous quarter transitioning from institutional settings into the community.
The enhanced reimbursement will be paid to providers outside of their single Medicaid rate during the BIP
eligible expenditure period (ending 9/30/15). The two-year enhancement is meant to facilitate a more rapid
movement of individuals out of institutional into community settings consistent with the OMH Regional
Centers of Excellence plan which calls for the downsizing of NYS operated inpatient psychiatric hospitals.
IMPROVE INFRASTRUCTURE FOR THE EFFICIENT PROVISION OF COMMUNITY LTSS ACROSS ALL
POPULATIONS
Note 14: Line Item – Expand NY Connects statewide and add features
NY Connects is New York State’s federally recognized Aging and Disability Resource Center. NY Connects
works as a coordinated system of information, assistance, and access for all New Yorkers seeking long term
services and supports (LTSS) resources. Through BIP, the current NY Connects programs, which consists of a
county-based partnership between the Area Agency on Aging and Local Department of Social Services
(and/or Community Alternative Systems Agency (CASA)), will be expanded to comprise additional partners,
potentially including the Regional Resource Development Centers (RRDCs), Developmental Disabilities
Regional Offices (DDROs), and Office for Mental Health (OMH) Regional Field Offices, as well as Independent
Living Centers (ILC’s and other Community Based Organizations representing individuals with disabilities .
Individual/caregivers will be able to access the NY Connects Network and obtain comprehensive, objective
information and assistance on LTSS through the website, a statewide 1-800 telephone number that will be a
virtual call center (routing calls to the NY Connects Network within the zip code of the person needing
information about or in need of LTSS); or in person, in the office, community or in the person’s home.
The NY Connects Network will minimize the need for “hand- offs.” Staff will be trained to provide consistent
information and assistance about available services, operate in accordance with NY Connects Standards and
Operating Protocols, conduct the Level I screen, utilize a person-centered approach, provide application
assistance for Medicaid and other publicly funded programs as appropriate, provide linkages to available
services for non-Medicaid eligibles, and assist individuals in linking to the appropriate Level II assessment
when Level I screen shows potential eligibility for Medicaid Community LTSS.
Through New York State’s participation in BIP, it is anticipated that there will be a significant increase in the
number of Medicaid recipients and Medicaid eligibles who contact NY Connects for information on LTSS.
With the roll out of a toll free number to help individuals across the State access information on LTSS, along
with potential inclusion of an enhanced Level I screening tool into the NY Connects LTSS Resource Directory
E.1-26
website (to be used by NY Connects staff and network partners or individuals themselves to determine what
services and if any financial assistance may be available to them for LTSS), NYSOFA estimates that currently
25 percent of individuals who contact NY Connects over the course of a year are Medicaid recipients or
eligible for the Medicaid program. Moreover, New York will develop a comprehensive advertising strategy to
promote the NY Connects Network of No Wrong Door system to ensure widespread awareness. The
dramatic increase in demand, particularly among Medicaid eligibles, requires commensurate capacity to
meet the demand to be built into the NY Connects programs and Network partners and increase the service
shed of the enhanced NY Connects Network to cover the entire State of New York. Expanding the geographic
and human resource capacity, as well as developing the necessary technological solutions to allow for the
interface of client information (in accordance with protocols to be developed to assure HIPAA and
confidentiality compliance), will enable a seamless and more timely experience for potentially eligible
Medicaid individuals/Medicaid recipients.
IMPLEMENT CORE STANDARDIZED ASSESSMENTS: for determining eligibility for community LTSS
in a uniform manner
Note 15: Category - IMPLEMENT CORE STANDARDIZED ASSESSMENTS: for determining eligibility for
community LTSS in a uniform manner
Integrating the OPWDD CAS and OMH assessments in UAS-NY
UAS-NY is the new uniform assessment tool being implemented statewide across 8 distinct Medicaid
programs administered by the Department of Health: Personal Care/CDPAP, Assisted Living Program, Adult
Day Health, Long Term Home Health Care Program, Care At Home Waivers, Nursing Home Transition and
Diversion Waiver/Traumatic Brain Injury Waiver, and Managed Long Term Care. The UAS-NY unified many
different assessment tools previously used across the Department's long term care spectrum.
During the planning and development process many features were added that apply to assessment tools and
processes across other agencies serving disabled populations whose long term care needs are funded
primarily by Medicaid. These features include allowing organizations to assign roles (which regulate access to
information and provide appropriate security and privacy) to their staff depending on the assessment
function they perform. The UAS-NY also contains:
•
•
•
•
•
•
•
an access portal that meets trust level III requirements,
features which allow assessments to be auto-populated with data from earlier entries,
standardized administrative reports,
on-line real time processing features and the ability for workers to use the tool off-line on
laptops,
integrated online training that requires users to complete certain courses before they can
access and use the assessment system,
the ability to replicate and transfer data to the warehouse and the Medicaid analytical
platforms, and
many other features which can be used by any agency regardless of population served.
However, in order for the UAS-NY to fully integrate the other core standardized assessments that are
currently at various stages of development in New York, other features are required. These include:
E.1-27
•
•
•
•
•
adding fully developed and validated assessment tools relevant to the developmentally and
behaviorally disabled,
adding access rights for organizations and users outside of the Department of Health,
adding business rules that reflect other populations processes and regulations which will
involve:
controlling the definition of roles and access, and
making the system recognize new programs for reporting purposes.
In addition, the integration of other instruments in the UAS-NY will require incorporating adjustments to the
standard reports, logic that points organizations to the proper assessments, content specific training and
other customization to ensure that the system works across the disability spectrum.
Other UAS-NY evolution to meet BIP requirements and support robust usage of current users
The UAS-NY funding for evolution and usage will largely be spent on supporting robust usage for existing DOH
organizations and their users. These organizations have new hardware requirements dictated by a secure
assessment system conducted in the home.
Secondarily, it will be used to integrate or interface with the NWD/SEP network as will be set forth in the
detailed design. This integration or interface will also dictate new reporting needs and desires, so standard
reports will have to be developed and new data elements will have to be accommodated. The Level I screen
will be implemented across the spectrum through the NWD/SEP approach and that will have to be integrated
with the UAS-NY and other core standardized assessment tools.
The system will also be evolved to include other populations served by the Department of Health such as
Health Homes. The system may be evolved to include Quality of Life Surveys, Quality Indicators and other
outputs.
NYS expects CSA to be linked to the website and 1-800 number; however, those specifications will fully be
revealed in the detailed designing process.
New York's CSA system (UAS-NY) will help achieve conflict free assessment and care planning by availing use
of defined roles for certain functions and not others; using organizations for certain roles and not others; and
providing both individual and aggregate data to state oversight entities as well as allowing plan and program
staff to see their own organization's trends. Furthermore, an automated, data driven CSA will help reduce
conflicts of interest between the assessment and care planning stage and the provision of services as well as
mitigate regional variations in assessment and care planning.
The CSA will capture data about an individual’s Medicaid status (whether approved, pending or not
applicable) which will enable the state to run reports and calculate the percentage of system usage for
Medicaid vs. non-Medicaid individuals. The state is currently evaluating the extent to which assessments will
be performed for individuals who are not Medicaid eligible.
The state will be able to identify software development and integration efforts for each project based on the
Agency requesting the development or enhancement in the UAS-NY. Both the assessment instruments and
business rules are discrete for each agency. The software development and integration contract is designed
to pay the vendor(s) by performance of specific functionality, which is and will be specified by each agency. It
is not anticipated there will be much “shared functionality” because the timing of the development is
E.1-28
significantly different for each agency. However, in the event that “shared functionality” is identified during
the integration of OPWDD and OMH assessments or for evolution projects, the state will use a relevant
accountable basis for allocations, which may be defined in the cross-agency cost allocation structure
currently under development or may include ratios involving numbers of individuals enrolled in agency
programs, numbers of regulated providers, plans or their users or other relevant numbers from the collection
of data.
MFP ADMINISTRATIVE RESOURCES: leverage for efficiency
Note 16: Line Item – Enhance MFP Administrative Budget
The current MFP protocol and approved budget does not account for the administration of transitions
related to the Mental Health/Behavioral Health populations served by the Office of Mental Health and set
forth in the BIP funding plan. This funding line recognizes that some or many of these individuals will be
transitioned to MFP qualified settings and the administration and tracking of these individuals should be
included in the MFP demonstration. The MFP protocol and budget will be amended to include these
populations and agency.
BIP REPORTING AND DATA COLLECTION: systems not in place
Note 17: Line Item – Develop Final Work Plan (protocols) & Quarterly Progress Report
NYS anticipates needing additional staff and contract assistance to meet all the work plan goals and
objectives.
Note 18: Line Items – Improve the overall quality of service delivery through additional staff
resources, as well as enhancements to information technology infrastructure AND Adopt practice
guidelines for care coordinators based on the Council on Quality and Leadership (CQL) personal
outcome measures (POM) AND Develop an Information Technology infrastructure that will
ultimately improve care coordination through the People First Waiver
Dollars needed for the establishment of DD specific long term care/managed care quality infrastructure and
metrics at individual, provider and system level that focus on individualized clinical and functional outcomes
specific to people with developmental disabilities. Long term care measures for specialized populations is an
area that has not been yet addressed cohesively at the national level. Therefore, specialized high level
expertise focused on this very important area is of paramount importance i.e., Medical and Clinical experts in
DD that also understand and can develop and implement a quality management system that integrates these
specialized measures and also focuses on utilization oversight and performance measures to ensure that
individuals with DD have the right services at the right time and in the right setting so that there is not a
deterioration in needed services over time or habilitation supports that ensure quality of life for this
vulnerable population. This must be supported by substantial IT infrastructure that will require 10 dedicated
E.1-29
IT staff resources to perform Project Management, Business Analysis, infrastructure builds, software
development, testing & quality assurance, and implementation and training functions.
Quality surveyors with nursing/clinical background and other Quality Related Staffing:
According to OPWDD’s expert consultant, OPWDD needs to develop consistent and uniform mechanisms to
audit the DISCOs and provider agencies on service access, timeliness, appropriateness, and outcomes of
clinical and administrative interventions.
OPWDD needs to hire additional surveyor staff with nursing and clinical backgrounds to perform on-site care
coordination reviews in DISCOs based upon these standardized mechanisms.
Staffing for Reviewing DISCO data/reports/encounter data vs. service plans and other data analysis capability
is also necessary to ensure quality oversight of DISCOs with this specialized vulnerable population.
OPWDD needs to develop an integrated reporting system that tracks and trends quality outcome data.
OPWDD needs the ability to capture data and produce analyses to perform proactive and capacity planning.
Program Integrity: With the shift to managed care, OPWDD is taking on additional responsibilities in the area
of program integrity. This has been an area of increased focus from CMS over the last several years and
OPWDD will have to develop and operate a comprehensive program integrity program tailored to the DD
population.
Functional Area/Positions and Number of Staff:
•
•
•
•
•
•
•
•
Quality Measures and Data Analysis : Program Research Specialists/Statisticians/Data Analysts would
be responsible for enterprise wide performance measure management (e.g., quality related data
collection and analysis) specific to developmental disability population, which includes the use of CQL
POMs in DISCO rating system and implementation of NCI (10 FTEs)
External Quality Review Functions Related to EQHRO and DISCO Performance Improvement Project
Development: This is a shared functions with DOH (5 FTEs)
DISCO Surveillance for DD Care Coordination Reviews: This requires 1 Administrator and 5 Nurses and
5 Surveyors for DISCO Care Coordination and Contract Reviews, Readiness Reviews and the
coordination of surveillance functions between OPWDD and DOH (11 FTEs)
Training: One staff person is required to conduct new and ongoing training for surveyor staff for CQL
POMs and move to person centered quality system (1 FTE)
Data Integrity: Nine staff are required statewide (one for each Area Office Director) to ensure data
integrity of survey findings and integrity of aggregated survey data utilized in performance measures
(9 FTEs)
Grievance and Complaints: This function requires 1 Administrator and 2 staff to coordinate and track
the grievance and complaints process between OPWDD and DOH as well as support
Member/Provider Services function within OPWDD (3 FTEs)
Professional Credentialing: This requires 1 staff for managed care professional credentialing policies
and procedures as well as for providing technical assistance (1 FTE)
Medical Director, Nurses and Clinical Staff: Currently OPWDD does not have a Medical Director. To
adequately support this function, 1 Medical Director, 5 Nurses and 5 Clinical Staff are needed (11
FTEs)
E.1-30
Information Technology Infrastructure:
Investment will be needed to continue the development of the People First Waiver Exchange, building on the
work of the SUNY/IBM innovation grant to create a managed care information exchange that is critical to the
efficacy of a managed care system. In addition, existing information systems will have to undergo a
fundamental shift from claims processing to encounter processing and reporting While the differences sound
small, the implications for systems impact is significant and should not be underestimated.
The Quality Assurance (QA) application will be replaced with a new web-facing application addressing the
data and business needs of the OPWDD Division of Quality Improvement including the inclusion of all DQM
protocols, multiple standalone databases, multiple interfaces with other applications, paperless surveys,
letters, and reports, DISCO access, CQL POMs, off-line data entry capabilities, Ad hoc reporting, a provider
record interface with TABS, a robust interface to a new Data Warehouse, and all requirements in support of
OPWDD's managed care transformation and DISCO oversight quality assurance efforts. This substantial IT
effort will require 10 dedicated IT staff resources to perform Project Management, Business Analysis,
infrastructure builds, software development, testing and quality assurance, and implementation and training
functions.
New York was not awarded a CMS innovation grant for the work envisioned in the State University of
New York (SUNY) and IBM concept proposal. However, the core technology elements envisioned in
the concept proposal remain as People First implementation goals.
The information technology structure for the People First Waiver intends to capitalize on existing
technology tools, systems and data used by other health and human service agencies and build only
what is necessary to address the unique needs of individuals with developmental disabilities and the
managed care and government oversight components necessary to effectively service these citizens.
The proposed required infrastructure is diagramed below:
E.1-31
People First Architecture
DOH
Data
Warehouse
Legacy
Systems
OPWDD
EHR
DISCO
(EHR)
Consumer/Family
Portal
OPWDD
RHIO
Provider
(EHR)
This infrastructure solution allows for the communication and exchange of data in accordance with
federal and State exchange protocols among the key parties involved in care coordination of individuals
with developmental disabilities: OPWDD, the Department of Health, DISCOs, providers of services and
the persons and families served.
The focus of this infrastructure design is on care coordination of individuals along with State
oversight of the managed care organizations’ performance. It also allows for a seamless expansion of
technology services as OPWDD transitions from initial voluntary enrollment phase to full
implementation of managed care.
This infrastructure reflects the reality that care coordination requires integration across multiple
entities and systems including the Department of Health, OPWDD, DISCOs, providers of services and
individuals/families. At the core of this infrastructure are:
•
DISCO EHRs: DISCO EHRs will serve as the care coordination tool for individual service plans,
oversight of its network of service organizations and source for quality monitoring information.
•
Data Exchange Structure: Building upon the requirements of federally certified EHRs, New York
will use the IT architecture of the State Health Information Network for New York (SHIN-NY). As
part of this structure, regional information exchange organizations (RHIOs) have already been
established to ensure interoperability of data exchange. DISCOs, their provider networks and
OPWDD’s EHR will connect to a RHIO to exchange data with other health care providers and as
necessary between DISCOs.
•
Data Warehouse and Data Marts: A critical feature for OPWDD is the creation of
developmental disability data warehouse and related data marts. Just as other New York State
health agencies are building data warehouses to serve their unique requirements, OPWDD
E.1-32
needs to develop warehouse capacity for the developmental disability population to ensure
coordinated and quality services. It is intended that OPWDD’s infrastructure will take advantage
of existing data warehouses in other State agencies (DOH in particular) and share the data
between the agencies.
Aspects of an OPWDD warehouse unique to developmental disabilities include:
o
o
o
o
o
o
Quality Assessment
System Capacity Documentation
Consistency of Care
Integration of provider and individual served information
Storage of key performance indicator components: Assessment Data, Individual Service
Plan, Encounter and Service information, citizen demographics, provider performance
measures,
Expandable to incorporate other data sets pertinent to individuals served, such as
information from foster care, employment, mental health, substance abuse, education
and criminal justice systems.
•
OPWDD EHR: As a leading provider of direct services, OPWDD needs to replace its paper
intensive manual processes with the functionality provided by an EHR system. As a statewide
service provider, OPWDD will be under contract with multiple DISCOs, and an OPWDD EHR will
allow for the automated and timely exchange of data between the DISCOs and OPWDD’s direct
care programs, implementation of operational and cost efficiencies and improved quality
monitoring.
•
Consumer Portal: Just as consumer portals are becoming a requirement for primary health
providers, a consumer portal for individuals with developmental disabilities, their families and
guardians will incorporate the specific service needs, quality measures, communications and
information pertinent to the developmental disabilities community.
Sustainability of Staff Positions:
The staff positions above are necessary to build capacity in OPWDD to support the transition to managed
care for the DD population. Much of this managed care infrastructure does not currently exist. It is
anticipated that the rebalancing of the DD system with managed care (i.e., delivering quality services through
better care coordination) will result in an efficient use of state and federal funding resources. These system
efficiencies will provide opportunities to sustain staffing through existing budgetary mechanisms after the
expiration of the Balancing Incentives Payments (BIP) program in September 2015.
OPWDD plans to reduce our footprint as it relates to the direct provision of services over the next several
years. The primary avenue through which this will be accomplished is a reduction of OPWDD-operated
campus-based program capacity to some 150 beds. However, unlike past campus closure efforts that sought
to expand community programs directly operated by OPWDD, we plan to predominantly rely upon our
network of partnering not-for-profit provider agencies to assume the responsibility to deliver compliant HCBS
Waiver services to these individuals in the community. As a result, State staff at impacted facilities are
expected to be redeployed to other vacancies across the remaining OPWDD-operated programs statewide, or
to support new services and/or activities such as the assessments of individual need, regionally-based START
teams to support individuals in the community in crisis instead of placements into more costly
E.1-33
hospital/institutional programs. Other significant initiatives supporting OPWDD’s objective to expand long
term care supports and services that will result in the redeployment of staff include PROMOTE, the Official
New York Training Program for the Support of People with Developmental Disabilities and the Core
Competencies adopted by the NYS Talent Development Consortium.
On Friday, November 1, 2013, OPWDD submitted its revised Comprehensive Quality Strategy to CMS.
This document outlines OPWDD’s Statewide Comprehensive Quality Management and Improvement Strategy
that incorporates Continuous Quality Improvement (CQI) processes and guides the activities of the NYS Office
for People with Developmental Disabilities in establishing, assessing, and improving the quality of services
throughout the NYS intellectual disability (ID) service system.
In accordance with CMS Technical Guidance[1], on components of a quality improvement strategy, OPWDD’s
Strategy document describes:
Roles and responsibilities of the parties involved in discovery, remediation and improvement
activities;
Processes for information gathering (i.e., discovery), remediation, and systems improvement;
(Section IV of strategy document)
Performance Measures which express discovery activities.
In addition, the OPWDD Quality Strategy outlines:
Key Quality Improvement Projects and Initiatives related to OPWDD’s Transformation goals.
The Quality Management Strategy also includes OPWDD’s 1915 C Waiver Quality Improvement Strategy
including the systems improvement activities followed in response to aggregated, analyzed discovery and
remediation information collected on each of the HCBS waiver assurances; the correspondent roles and
responsibilities of those conducting, assessing and prioritizing system corrections and improvements; and the
processes followed to continuously assess the effectiveness of the Quality Strategy and revise it as necessary
and appropriate. The OPWDD Quality Strategy also incorporates the following:
OPWDD Transformation Evaluation Plan: describes how OPWDD will assess the degree to which the
key goals of the transformation plan are achieved and how the key activities of the transformation
plan are implemented.
OPWDD Transformation Accountability Plan: details specific measures which will be used to actively
track progress of the Transformation Plan, endeavoring to ensure that quality and access are fostered
throughout the transformation, including the transition to managed care.
OPWDD Strategy for Transition and Expanding Housing Options: Appendix F-1, submitted to CMS
on August 30, 2013 for BIP deliverables 13.1 and 13.2.
[1]
CMS Instructions, Technical Guide, and Review Criteria for 1915 c waivers, Version 3.5, page 11
E.1-34
OPWDD’s Work Plan Affirming its Commitment to Establish an Independent Person Centered
Planning Process and Progress Towards Council on Quality and Leadership CQL Measures:
Submitted to CMS on September 1, 2013.
Quarterly Report & New York Draft Plan To Increase Competitive Employment Opportunities For
People with Developmental Disabilities Submitted to CMS on October 1, 2013
OPWDD conducts annual reviews of all HCBS waiver providers (including state operated waiver
providers) that addresses waiver assurances, person centered service delivery, health and safety of
waiver participants, and variety of other factors and quality domains.
These reviews will continue as HCBS waiver services and service delivery approaches are modified to
accommodate individuals transitioning from ICFs and developmental centers. More detail on DQI’s
discovery processes through surveys are outlined below:
•
On-Site Surveys by DQI: DQI’s survey processes and protocols are extensive and comprehensive
and reflect a review of the major elements of regulations, provider responsibilities, health and
safety of individuals served, person centered planning and service coordination, service delivery,
environmental/physical plant reviews, medication administration, infection control, personal
allowance, rights, informed consent, individualized planning, etc. Surveyors conduct
unannounced visits/inspections and utilize a variety of techniques to gather information
including observation, interviews, documentation reviews, and facility and physical plant reviews.
All providers are visited at least annually through on-site HCBS waiver reviews, reviews of MSC,
and reviews of OPWDD certified sites and facilities. More detailed information on OPWDD’s
survey processes and protocols can be found in the 1915 C Waiver Application and on OPWDD’s
website at:
http://www.opwdd.ny.gov/opwdd_services_supports/service_providers/division of_quality_improvement_protocols
In addition, Provider Performance Transparency Reports are published on OPWDD’s website at:
http://www.opwdd.ny.gov/opwdd_services_supports/service_providers/provider_performance/reports/listing
Remediation: The methods used by DQI to remediate individual problems as they are
discovered through the survey process include the following:
•
Through annual and recertification survey visits/activities, notification is provided to all
providers of regulatory deficiencies.
•
When warranted, generation of Statements of Deficiency (SODs) which require a Plan of
Corrective Action (POCA)
•
Review and analysis by DQI of all POCAs submitted by providers. If a POCA is deemed
unacceptable by DQI, the provider is required to amend and submit an updated/acceptable
POCA. DQI conducts follow up visits when warranted to ensure that corrective actions have
E.1-35
been implemented by provider agencies. Corrective actions are also reviewed by DQI upon
recertification of operating certificates and during HCBS reviews.
•
When significant issues are found in provider agency operations, providers are referred for
mandatory board training conducted by OPWDD or an approved trainer/training entity.
•
DQI conducts statewide provider training to update the provider community on changes in
policy, clarify expectations, and to share best practices and remediation strategies.
•
Providers that experience systemic programmatic and fiscal issues are referred to the Early
Alert Committee for concentrated remediation efforts and more intense monitoring and
follow up. OPWDD’s Early Alert Committee: is an inter-agency discovery process utilized to
proactively identify providers that may show signs of decreased quality enabling OPWDD to
take timely and definitive action.
In order for OPWDD to move to a managed care environment, OPWDD must create two organizational
models. The first model is OPWDD’s role as a provider. This model will require OPWDD to have an Electronic
Health Record for each individual that OPWDD services. The second model is OPWDD’s role as an oversight
agency. The oversight model will require OPWDD to create and maintain a data warehouse and data marts
to analyze the various data sets that will come from the managed care providers.
•
Electronic Health and Care Management Records:
At the core of every DISCO’s automated information system will be federally certified vendor EHR
products used as a baseline for ensuring system integrity, functionality and data exchange standards.
At the same time, it is recognized that EHRs developed for primary care organizations require
customization to meet the more holistic needs of individuals with developmental disabilities. These
required customizations are being identified by OPWDD and by the DISCOs responding to the
upcoming release of OPWDD’s RFA for managed care services.
Even as EHRs incorporating disability care management are recognized as a central component of
effective managed care services, such automation of medical and care services is required by the
provider community, including the provider services operated by OPWDD. To ensure system
capability, an assessment survey is being issued to the provider community to document its readiness
for electronic health care communication.
OPWDD fee-for-service programs may have limited involvement with the pilot DISCO program at the
onset; however, as the managed care initiative expands, these OPWDD managed services will take
the same form as any other provider of services being overseen by a managed care entity. To this
end, the OPWDD managed programs will need to electronically record and communicate service
data, and be able to document quality service metrics consistent with all other providers of services
to managed care entities.
Currently, OPWDD does not have an EHR. One would need to be procured via an RFP. Monies for
hardware, software and twelve (12) staff will be required to select, implement and maintain the
system as well as train users. The current timeline is 9 – 12 months to complete the project.
E.1-36
•
Data Warehouse and Data Marts:
A critical feature for the State is the data warehouse and related data marts. State agencies need to
develop warehouse capacity to reflect coordination and quality elements associated with BIP
requirements and objectives. The state will take advantage of existing data in the warehouse and
connect all the data between the agencies. The State will also capitalize on the integration of State IT
technologies to take advantage of the data warehouse hardware and software originally developed
for the Office of Mental Health and now available for use for other agencies. Saving the millions of
dollars in infrastructure development, the state will be developing and managing the data structure,
analysis and reporting related to all populations.
Additional aspects of the warehouse related to BIP include:
o
o
o
o
o
o
o
Quality Assessment
System Capacity Documentation
Consistency of Care
Integration of provider and consumer information
Storage of key performance indicator components: Assessment Data, Individualized Service
Plan, Encounter and Service information, citizen demographics, provider performance
measures,
Expandable to incorporate other data sets pertinent to individuals served, such as
information from foster care, employment, mental health, substance abuse, education and
criminal justice systems.
Performance dashboards and monitoring tools for managers, DISCOs, providers and the
public. Alerts and current health related data will be transmitted in real time to provide the
most up-to-date information for the care of all individuals.
In accordance with the BIP requirements, core IT infrastructure components will be implemented
across state agencies. This integration will be possible in no small part due to the consolidation and
integration of State information technology services within the State Office of Technology Services
(ITS) which heretofore had been an agency-by-agency siloed responsibility. With this IT
consolidation, IT services and application development is no longer the purview of individual
agencies. Rather all IT health initiatives are overseen by an executive governance board made up of
the agency heads from the State’s nine health agencies and chaired by the Governor’s Deputy
Secretary for Health. Part of this executive board’s charter is the integration of IT services across
agencies to achieve operational and cost efficiencies. The Governor’s Office has organized the board
to exam key technologies for integration such as data sharing, care management/EHR, provider
performance/oversight and incident reporting. Under the auspices of the board, all IT projects are
overseen by ITS’ Office of Project Management and coordinated through the board. Until such time
as a formal cost allocation plan is approved, IT costs will be tracked among programs through a time
and attendance program where employees identify work time spent per project.
Note 19: Line Item – DOH/OMH responses for improving quality after measuring
As new services and supports are being offered in the community to support those transitioning from
facilities or other less integrated settings, individuals use of those offerings must be supported by
E.1-37
assessments, care plans and service plans. NYS does not intend to build capacity to serve individuals in the
community without mechanisms to assure the new capacity gets to the right individuals at the right time.
This involves implementing a formal process which assures assessments, care planning, service planning and
authorizations are in place across the agencies for increased capacity. This also includes assuring the
NWD/SEP network staff is informed timely and consistently and information systems are updated in the same
way.
So, NYS will have to organize and hire staff for this process to control change.
DEDICATED RESOURCES TO MANAGE STRUCTURAL IMPROVEMENTS: under BIP note in place
Note 20: Line Item – Enhance service planning and case management systems to include electronic
processes which capture new data to support the right people are getting the right services at the
right time
Conflict Free Case Management involves separating duties for functions which may cause service delivery
bias. This funding line involves changing the myriad of disparate service planning and case management
systems in place across the agencies to include new offerings and increased capacity which will enable
individuals to be served in the community.
Relationship between the activities described above and investment in DISCO EHR efforts:
Conflict-free Case Management will involve separating functions into four components, each of
which will be managed by a separate entity and integrated within the DISCOs EHR. These
components are:
o
Intellectual and Developmental Disabilities Determinations and Assessments for Services: As
described in the response to the Deliverable 8.2: CSA/CDS Crosswalk question above, these two
functions are separate and distinct and both will be independent from the responsibility of the
DISCO.
The Intellectual and Developmental Disabilities Determination is a review conducted by OPWDD,
of the person’s clinical record demonstrating substantial disability that meets the standards set
forth in Mental Hygiene Law 1.03 (22).
To ensure the separation from direct services, the assessment process for services will be made
by an organization that has no fiscal relationship to the provision of services. This coordinated
assessment system (CAS) will be part of DOH’s Uniform Assessment System (UAS-NY) and will be
administered by either a broker hired by OPWDD or by OPWDD personnel. Once a person’s
appropriateness for services has been determined, this needs assessment will be transmitted to
the appropriate DISCO.
o
Development of Individual Service Plan: Upon receipt of the needs assessment, the DISCO shall
be responsible for developing an electronic individual service plan. Each component of the
E.1-38
service plan will link within the EHR to the independently determined eligibility for specific
services. The EHR will flag needed services that are not addressed in the service plan as well as
timeliness of service plan’s development. The EHR will also automatically:
o Provide the service plan’s specific components to the individual (parent/guardian) through a
consumer portal and hard copy mailing.
o Electronically transmit the service plan components to OPWDD’s data warehouse.
o Ensure that the service plan complies with OPWDD standards, business rules and best
practice requirements.
o
Care Management Services: The direct services that are called for in the individual’s service plan
will be established by the DISCO through the DISCO’s network of direct service providers. To the
extent that the DISCOs are also direct care providers, firewalls will be established within the EHR
functionality to ensure an individual’s choice of services. As part of these firewall features, the
EHR’s will automatically flags such instances and report the information to OPWDD as the State
oversight agency.
o
Quality Monitoring, including review of assessment, service plan development and actual
services. Through the use of the DISCO EHR’s automated functionality, direct links will be
established between the record of an individual’s eligibility for services, the service plan
addressing eligible services, the direct services linked to the plan and the actual delivery of
services that are called for. Automated functionality within the EHR will provide multiple quality
management features, including:
o preventing services being included in the service plan for which the person is not eligible;
o preventing direct care services being provided that cannot be linked to the needs assessment
or service plan;
o flagging the failure of direct service providers to perform the functions called for in the plan;
and
o providing quality monitoring reports directly to the DISCO’s quality management team,
OPWDD as the oversight agency and to individuals (parents/legal guardians).
Quality monitoring will also address grievances and incident reporting processes as additional checks on
service quality and performance. These functions will be incorporated within the EHR, and depending upon
the nature of the situation handled either by DISCO management under OPWDD’s oversight or directly
handled by the State’s independent New York State Justice Center for the Protection of People with Special
Needs.
Note 21: Line Item – Enhance reimbursement for residential services to enlist a sufficient pool of
providers to support non-campus based transitions (Still Pending)
OPWDD faces a significant challenge in transitioning people now served in institutional settings into
integrated, community based opportunities. This is a population with which we do not have extensive
community-based planning experience. Additionally, our current needs assessment tool (the Developmental
E.1-39
Disabilities Profile – or DDP) does not accurately address this population because it is not sensitive to the
high-intensity, low-frequency behaviors.
In order to achieve the transformation agenda goals related to transition from institutional care to fully
integrated community settings, OPWDD is proposing to establish transitional fees that will incentivize
providers to support individuals moving from institutional programs to integrated community opportunities.
These transitional fees will reimburse providers at set amounts that are greater than existing reimbursement
levels, on average, to ensure that the appropriate levels of supports – staffing or otherwise – are available to
facilitate a successful transition. The fees will also provide for the development of supports that are tailored
to the individual needs and choices of each person leaving an institutional setting and will encourage
supports that result in opportunities for person controlled housing, employment and self direction. These
fees will vary and be dependent upon the needs of the individual and the level of service provided to meet
those needs in the current institutional setting (higher fees for individuals with high needs leaving more
structured programs) as well as the region in which the individual has chosen to reside (to reflect cost
differences). It is anticipated that fees will be available for both residential and day services, and that
reimbursement will ultimately be predicated upon individual need, once the Comprehensive Assessment
System, which is under development, is fully validated and implemented. In addition to the residential and
day fees, for individuals leaving institutions and opting to self-direct their services, a similar approach will be
applied to the Consolidated Support and Services budgeting process to allow for the consideration of higher
levels of budgeted services that will support needed community-based supports.
OPWDD is proposing to reimburse providers at the following enhanced amounts, exclusively with BIP
funding:
The transition fee is time-limited. OPWDD is working on the development of a new, assessment tool, the
Comprehensive Assessment System (or CAS). OPWDD and DOH will evaluate the CAS-assessed needs of
E.1-40
individuals leaving institutions and adjust the standard methodology to incorporate a needs-based acuity
adjustment that will be described in the HCBS waiver amendment, with the goal of replacing the DDP tool.
E.1-41
Appendix F.1: Description of settings in which ID/DD population
currently resides and Description of Strategy for building housing
options for the ID/DD population
F.1-1
OPWDD: Putting People First
August 30, 2013
Balancing Incentives Program Work Plan
Appendix F.1
(13.1 & 13.2 Deliverables)
Submission to the Centers for Medicare
and Medicaid Standards
F.1-2
OPWDD: Putting People First
Table of Contents
Introduction…………………………………………………………..…………………1
Settings where People Live Currently ……………………………………..……….1
Traditional Housing Models…………………………………………………………….1
Non-Traditional Housing Models…………………………………………………….2
Strategy for Transition and Expanding Housing Options ……………..…………….5
Expanding Home and Community Based Housing Models…………………………5
Increasing the Availability of Community Housing Options ……………………….8
Housing Goals…………………………………………………………………………….8
F.1-3
OPWDD: Putting People First
Introduction
Affirming New York State’s commitment to build upon current efforts to rebalance the delivery of long term
services and supports (LTSS) as agreed upon under the State’s Balancing Incentives Program (BIP) Grant
agreement, and consistent with the federal Olmstead v. L.C. decision, the following demonstrates the Office For
People with Developmental Disabilities’ (OPWDD) commitment to the goal of improving access to home and
community based long term care services and supports for people with intellectual and/or developmental
disabilities (ID/DD) throughout the State.
Specifically, this document represents BIP Work Plan deliverables 13.1 and 13.2 as highlighted below and meets
the requirements of the Health System Transformation for Individuals with Developmental Disabilities
Agreement as defined in the Standards Terms and Conditions of New York State’s Partnership Plan Medicaid
Section 1115 Demonstration.
13.2 Describe all settings in which the ID/DD population currently resides: This description includes
the number of individuals in group homes, small ICFs/IDD, large ICFs/IDD and nontraditional housing models. Each setting type above should include the maximum
number of individuals living in the residence, and any type of licensure or
accreditation required.
Settings where People Live Currently
The following describes the types of traditional and non-traditional settings where individuals reside today
within the OPWDD system including the maximum number of individuals living in the residence and the type of
licensure or accreditation required, where applicable. Total capacity for OPWDD traditional and non-traditional
settings is outlined in the current settings table on page 4 of this report. OPWDD has continued to strive to
expand and improve community based long term care services and supports for people with intellectual and/or
developmental disabilities (ID/DD) over the last several decades and affirms its commitment to this goal under
the BIP grant and Transformation Agreements. To date 23% of the individuals residing in certified settings live
with 4 or fewer people. In addition, based on OPWDD’s Tracking and Billing System (TABS), of the 126,000
individuals who receive OPWDD services approximately 70% are living independently or are supported in their
family’s home.
Traditional Housing Models
Individualized Residential Alternatives (IRA)
An IRA is a community residence certified by OPWDD that provides individualized services consistent with each
person’s interests, aspirations, and support needs. These homes provide a homelike environment in typical
neighborhoods for individuals to participate in the mainstream of community life. Each person living in an IRA
has an individualized plan which includes his or her personal goals and the levels of support needed in areas of
daily living and community life. Support needs of persons residing in IRAs vary markedly from mild to
intensive. A “Supervised IRA” provides 24 hour staff support for no greater than 14 persons in one setting. A
F.1-4
OPWDD: Putting People First
“Supportive IRA” provides as needed staff supports for individuals who need intermittent assistance to maintain
their independence in the community. While supportive settings may be home to up to four persons in any one
setting; the majority are apartment settings where 1 or 2 individuals reside. The authority to establish IRA’s is
found in NY State Mental Hygiene Law and standards of certification are located at NYCRR Parts 686.16, 635, 633,
and 625 and 624.
Community Based Intermediate Care Facilities (ICF)
A community based ICF’s primary purpose is to provide health and habilitative services to people with
developmental disabilities in residences of four or more persons located in the community. ICFs support
individuals whose functional abilities require the provision of continuous active treatment services with the goal
of assisting an individual to attain the skills needed for full integration in the community and who are not able to
safely care for their basic needs in one or more areas of adaptive behavior or daily living. Many require intensive
medical, health related, and or behavioral supports. Community Based ICFs providing 24-hour staffing in
community settings are operated by both the State and not-for-profit providers. These setting have no size
restriction, but the vast majority serve 30 individuals or fewer. ICFs must comply with the requirements of Title
42 Code of Federal Regulations (CFR) 483, Subpart 1, as well as federal HCBS settings standards and NYCRR
Parts 633, 635, 625, 624, and NFPA 101 Life Safety Code (LSC).
Non-Community Based Intermediate Care Facilities (ICF)
A Non-Community Based ICF’s primary purpose is to provide health and habilitative services to people with
developmental disabilities in residences of four or more persons on the campus of a Developmental Center. ICF’s
support individuals whose functional abilities require the provision of continuous active treatment services with
the goal of assisting an individual to attain the skills needed for full integration in the community and who are
not able to safely care for their basic needs in one or more areas of adaptive behavior or daily living. Many require
intensive medical, health related, and or behavioral supports. Non-Community Based ICFs provide 24 hour
staffing on developmental center campuses and have no size restriction. ICF’s must comply with the
requirements of Title 42 Code of Federal Regulations (CFR) 483, Subpart 1, as well as NYCRR Parts 633, 635, 625,
624, and NFPA 101 Life Safety Code (LSC).
Non-Traditional Housing Models
Living at Home with Family or in Non-certified Settings
This category, living at home with family, includes people who receive Family Support Services (FSS) and those
who do not but reside in a private residence (private home, apartment or family residence). FSS is a family
directed, statewide system of comprehensive services which help families provide in-home care to family
members with a developmental disability. One popular support is respite care, which provides relief for families
who care for loved ones at home. Respite is time-limited and temporary – allowing families time for errands,
vacations and other planned activities.
Family Care Program
A Family Care residential program provides community-based residential housing in private certified homes to
provide support, guidance and companionship to individuals who do not require residential care and treatment
in a more restrictive residential setting but who are unable to function adequately in their own homes or in
independent living arrangements in the community.
F.1-5
OPWDD: Putting People First
Homeownership
The homeownership program allows income-eligible first time home buyers who have an intellectual and/or a
developmental disability (ID/DD) and the parents or the legal guardians of someone with an ID/DD to purchase
their own home with a specialized mortgage product created by the State of New York Mortgage Agency
(AGENCY) for people with ID/DD implemented through M&T Bank. This program has been operating since
1997.
Supportive Housing
The general term used to describe subsidized housing “supported” with on-site services that are person-centered,
self-directed, and needs-driven. Rent is usually set at 30% of the tenant’s income.
Living in Apartments (types)
Market Rent Apartments: Housing establishments that have no government subsidy. The real estate
market determines the rent levels. Some market rate rentals offer a broad range of services, including
meals, housekeeping, and transportation. (NYSHCR Guidelines).
Subsidized Apartment: Rental buildings that serve low income individuals. These are established by the
U.S. Department of Housing and Urban Development (HUD) and vary within each county. They are
owned by private or non-profit organizations and their construction and operations have been financed
with federal and state resources.
Manufactured Housing/Mobile Homes
A type of pre-fabricated housing that is largely assembled in factories and then transported to sites of use.
Manufactured Homes are built as dwelling units of at least 320 square feet in size with a permanent chassis to
assure the initial and continued transportability of the home. The requirement to have a wheeled chassis
permanently attached differentiates “Manufactured Housing” from other types of pre-fabricated homes, such as
modular homes.
Shared Living Arrangements
Share living apartments is a highly individualized home care model for people of any age and disability where
individuals choose where they live and who provides the support. Shared Living is also referred to as supported
living, Family Care, Foster Care, Specialized Home Care, and life sharing.
Customized Residential Options
A customized residential option is when a non-profit agency purchases a single family home and rents the home
to people with ID/DD. Each “tenant” has his/her own lease and a Social Contract is established within the home.
Public Housing
Public housing provides affordable rental housing opportunity for eligible low-income families, the elderly, and
persons with all types of disabilities.
F.1-6
OPWDD: Putting People First
Settings where People Live Currently
Where People Are Living
Capacity
Maximum # of
Enrollment
Licensure/Accreditation/Notes
Traditional Certified
Housing Settings
Total: 36,234
Individualized
Residential Alternatives
(IRA)
28,912
No > 14
NY State Mental Hygiene Law and standards of
certification are located at NYCRR Parts 686.16,
635, 633, and 625 and 624
Community Based
Intermediate Care
Facilities (ICF)
6,328
No size restriction
Title 42 Code of Federal Regulations (CFR) 483,
Subpart 1, as well as NYCRR Parts 633, 635, 625,
624, and NFPA 101 Life Safety Code (LSC).
Non-Community Based
Intermediate Care
Facilities (ICF)
994
No size restriction
Title 42 Code of Federal Regulations (CFR) 483,
Subpart 1, as well as NYCRR Parts 633, 635, 625,
624, and NFPA 101 Life Safety Code (LSC).
More Integrated Settings
Living at Home with
Family**
Total: 90,266
43,512
N/A
The 43,512 count is based on participants known to
be living with their families by virtue of their
receipt of 100% State Funded Family Support
Services (FSS)
Family Care
2,182
No > 6
NY State Mental Hygiene statutory authority and
standards of certification are located at NYCRR
Parts 687.3, 687.4.
Living in Own Home
(private residence with or
without roommates)
2,528
N/A
The 2,528 count is based on participants known to
be living independently by virtue of their receipt of
100% State Funded Individual Support Services
(ISS)
Living Independently or
with Family**
42,044
N/A
The 90,266 total figure is based upon OPWDD
census for individuals who are both Medicaid and
non-Medicaid enrolled. Current census data does
not accurately identify living type of arrangement
in all cases. Therefore, there remain 42,044
individuals who are supported by OPWDD in noncertified settings, but data does not identify
whether the person lives independently or with
family.
**People living in these categories may fall within the non-traditional housing descriptions outlined in the narrative
section above. OPWDD is working to capture more accurate data on an individual’s living arrangement through
improved data collection that will support and assess the achievement of the Developmental Disability
Transformation Agenda and Olmstead Goals.
F.1-7
OPWDD: Putting People First
Strategy for Transition and Expanding Housing Options
13.3
Describe the strategy for building housing options for the ID/DD population and supporting
transitions. This document should include NY’s plan to transition the remaining 160
residents of the Finger Lakes and Taconic ICFs prior to December 31, 2013, to
community-based settings that meet CMS HCBS settings standards and a transition
timeline for the residents of the remaining campus and non-campus-based ICF’s
The below table2 distinguishes the number of people, reported in the Balancing Incentives
Program Work Plan Appendix F.1, “Settings Where People Live Currently” table, residing in IRAs
within the requested ranges. All 2,182 individuals living in Family Care settings reside in a home
with 4 or fewer individuals with developmental disabilities.
IRA
Capacity
<5
5-10
11+
Total
# of
Individuals
6,319
18,187
4406
28,912
Expanding Home and Community Based Housing Models
Over the years, OPWDD has reduced its reliance on the ICF model of care, and many fewer individuals reside in
both campus based and community based ICF settings today than in previous years. When Home and
Community based waiver services were introduced in New York, the number of individuals who were living in
ICFs dropped dramatically as individuals, their families and providers chose to move in the direction of more
integrated supports, tailored to the needs and desires of the person that the waiver offers. In keeping with
Governor Cuomo’s Olmstead goals for NYS as well as OPWDD’s long standing commitment to
deinstitutionalization, the agency has made public its plan to close 4 more campus based ICF institutions. The
draft multi-year timeline for transitioning the closure of these ICF institutions is detailed in the table on the next
page. Together with the ongoing closure efforts at Finger Lakes and Taconic, this will reduce the remaining
campus census by another 800 individuals, while keeping the remaining campus based opportunities to no more
than 150 by 2018. These will be available to meet short term intensive treatment needs of individuals who require
this level of care for their safety and to assist in transition to the community as quickly as possible.
In addition, OPWDD will work with its providers to enable the individuals who currently reside in community
ICFs to get their residential supports in more integrated settings, including Individual Residential Alternatives
(IRAs) with HCBS waiver supports and more individualized and nontraditional housing. As shown in the ICF
Transition Plan below, it is expected that over the next 5 years, the community ICF population will be reduced
from the current census of over 6200, to around 500.
All of the individuals who reside at both Taconic and Finger Lakes campuses have individual plans for
community services which are under development. Their ICF treatment teams have worked together in this
2
This table was added as a result of questions from CMS and was not part of the original submission of the report to CMS.
F.1-8
OPWDD: Putting People First
planning effort with the individuals and their family members as well as the agency they have chosen to provide
their community based supports. The target date for all remaining moves to occur is 12/31/13 with 20 additional
transitions occurring by October 1, 2013 and the remaining 121 moves planned before year’s end.
The individual plans provide for most individuals to move to community homes that meet HCBS requirements.
There are 55 individuals who will move from the Finger Lakes and Taconic campuses to MFP qualifying settings.
Currently there are 6 individuals at Finger Lakes and Taconic who continue to require ICF level of care and for
whom plans have been made to move to another campus where they can continue with treatment that will enable
them to move to a more integrated setting.
F.1-9
OPWDD: Putting People First
Housing Options
CERTIFIED HOUSING:
SOICF- CAMPUS
SO ICF- COMMUNITY
VOICF
IRA SUPPORTIVE
IRA SUPERVISED
August 1, 2013
2014
2015
2016
2017
October 1, 2018
994
659
5669
2227
26685
731
593
5102
2326
27088
493
504
4337
2475
27693
268
428
3686
2624
28298
181
257
2211
2823
29104
150
0
456
3221
30721
This plan includes opportunities for 1048 people to move into person controlled housing by Oct. 1, 2018.
F.1-10
OPWDD: Putting People First
Increasing the Availability of Community Housing Options
To increase the availability of community housing options, OPWDD is actively engaged in maintaining existing partners
in the housing industry and cultivating new partners. The following provides a summary of OPWDD’s goals and
strategies for increasing the availability of community housing options. With each BIP Work Plan update, OPWDD will
report progress in attaining these goals and implementing these strategies.
There is no one specific type of residential setting that will meet the needs of all people with developmental disabilities;
therefore, OPWDD’s strategies center around the identification and development a continuum of community housing
options that is based on the service needs and preferences of the individual and his or her available resources.
Within the past few years, OPWDD has focused on maintaining and strengthening existing partnerships in the housing
industry, designed to increase the availability of housing opportunities and develop new and innovative partnerships
that will expand our capability to offer more individualized housing options. The agency has an aggressive information
and outreach system which provides an opportunity for partners to be educated, trained and provided with ongoing
technical assistance. OPWDD is also actively soliciting input from its stakeholders about innovative housing models and
best practices.
Housing Goals
Goal One: Expand the Inventory of housing alternatives for people with Developmental Disabilities
Goal One sets in motion the expansion of an interagency partnership with multiple state agencies to leverage resources
and provide additional rental units. The use of state agencies’ resources will incentivize developers to create additional
accessible and affordable housing for people with developmental disabilities.
Goal One Strategies
• Pursue and leverage increased local, state, and federal rental subsidy opportunities
• Provide incentives for developers to build units for individuals with developmental disabilities within their “regular”
apartment settings
Goal Two: Increase Access to Rental Subsidies
Goal Two reflects efforts to increase the funding pool for subsidizing rental units for people with developmental
disabilities through policy changes, funding requests from federal agencies, and partnerships with state and local
municipalities. OPWDD proposes to explore a pilot rental assistance model to identify and assess the most effective way
to provide affordable, accessible, and high quality rentals for people with developmental disabilities now and in the
future.
Goal Two Strategies:
• Seek policy changes at the federal level in the expansion and distribution of housing choice vouchers for people with
disabilities.
• Partner with state and local public agencies to prioritize rental subsidy needs of people with developmental
disabilities.
• Partner with local public agencies to track the distribution of housing choice vouchers for people with disabilities.
• Pursue and develop funding sources to expand the availability of rental assistance.
Goal Three: Build understanding and awareness of housing options for independent living
Goal Three intends to generate increased awareness of and interest and engagement in moving from congregate homes to
housing alternatives. A systemic outreach and marketing effort by all state agencies involved in the Interagency Housing
F.1-11
OPWDD: Putting People First
Council will assist with this effort. Also, OPWDD’s Continuum of Housing Options Roundtables offer provider agencies
and families an opportunity to highlight innovative and promising practices in housing alternatives.
Goal Three Strategies:
• Develop and implement a communications, advocacy, outreach and education plan.
• Build the capacity of public and private agencies to assist people with developmental disabilities in making informed
choices.
• Continue to host Housing Forums on housing options currently available to people with developmental disabilities.
Forums are broadcast statewide to interested parties through the use of Video- and Tele-Conferencing.
• Initiate a series of educational Webinars on “how-to-create” housing alternatives for independent living.
Goal Four: Increase Collaboration
Increase collaboration among OPWDD, state and federal agencies, voluntary providers, advocacy groups and families to
create a more efficient and effective path for people with intellectual and developmental disabilities to access and receive
the supports and services they or their family need.
Goal Four Strategies:
• Align the work of OPWDD’s Office of Home & Community Living to support the following NYS initiatives:
o NYS Money Follows the Person Demonstration
o NYS Balancing Incentive Program
o 1915 B/C waiver applications
o Residential transitions and expansion of supportive housing
o Supportive employment services
o Increasing self-direction
• Continue to promote dialogue with and seek input from individuals, family members and providers on innovative
housing models that hold promise for effectively supporting individuals with developmental disabilities.
What’s been done, to date
In order to increase the availability of supportive housing options, there must be a concerted effort to maintain existing
partners in the housing industry and cultivate new partners. It is also necessary to educate, train and provide technical
assistance to public and private sectors, administrators in the human services industry, front line workers and others, and
to glean knowledge of innovative housing models and best practices from individuals, families and the provider
community. Below is a summary of OPWDD’s efforts to maintain and create new partners in the housing industry. Also
included is a listing of education, training and technical assistance efforts.
F.1-12
OPWDD: Putting People First
Maintaining Existing Partnerships
Some Federal Partners
United States Department of Housing and Urban Development (HUD): OPWDD is a HUD-Approved Housing
Counseling Program
United States Department of Agriculture (USDA) Rural Development
• Enhanced existing MOU with USDA to include multi-family homes in rural areas – Signed new MOU in 2013 to
include Multifamily Homes.
• Invite USDA Rural Development representatives to present at various OPWDD housing forums.
• Maintain a listing of all USDA Foreclosed homes, distributed this listing to the respective OPWDD Regional Offices.
• Attend local USDA Rural Development functions.
United States Department of Health and Human Services (HHS) – Assets For Independence (AFI)/Matched Savings
Program
• Awarded $1 million from HHS to assist people with intellectual and developmental disabilities, their income eligible
parents or legal guardians save the down payment and closing costs for their 1st home.
Some State Partners
New York State Homes and Community Renewal (HCR)
• Expanding existing partnership with HCR for housing units targeted to those with developmental disabilities and
State of New York Mortgage Agency (SONYMA).
• Expanding partnerships with SONYMA to continue growth of the Home of your Own program for those with
developmental disabilities who are interested in purchasing their own home.
• Hosted Meet and Greet sessions between OPWDD Leadership, Affordable Housing Developers, OPWDD provider
agencies and HCR Supportive Housing representatives to begin dialogue on supportive housing for people with
intellectual and developmental disabilities.
• Trained HCR staff on how OPWDD’s funding mechanisms for non-certified housing settings work.
• Invited HCR to present to OPWDD’s leadership on its housing programs at both OPWDD’s Housing Forums and
Provider Association meetings.
• Received scholarships from HCR to attend Housing Counseling training through NeighborWorks America.
• Participated in pre-development meetings for agencies awarded funds through HCR’s Unified Funding Round.
• Participated in HCR Public Hearings for Small Block Grants.
• Established a formal and ongoing commitment to participate in HCR’s Housing Trust Fund.
State of New York Mortgage Agency (SONYMA)
• Provided training for SONYMA Regional Loan Originators.
• Advocated with M&T Bank to have Loan Originators for the HOYO program in each region of NYS.
• Worked with SONYMA to expand the AFI program statewide.
Governor Cuomo’s Medicaid Redesign Team (MRT) Supportive Housing Development Program
• Provided funding to 11 agencies with MRT’s initial funding round which resulted in individuals with disabilities
moving from more restrictive settings into community placements with supports.
F.1-13
OPWDD: Putting People First
Current activities to develop a full continuum of housing options
• Expanding the OPWDD Family Care model of housing alternatives through recruitment, updated payment
structures, professional models of staffing, etc.
• Expanding priority options for NY Homes and Community Renewal (HCR) to support including units for people
with developmental disabilities in the creation of new housing opportunities and renovations of existing housing.
F.1-14
Appendix G: Acronym List
G-1
Acronym
AAA
ABD
ACA
ADHC
ADRC
ALP
BCM
BH
BHO
BIP
C-SPOA
CAH
CAHPS
CAN
CANS-NY
CAP
CAS
CASA
CBO
CDPAP
CDS
CDSMP
CEO
CFCM
CFCO
CFR
CHHA
CM
CMH
CMS
COA
CQI
CQL
CSA
CSE
DD
DDP-2
DDRO
DDSO
DISCO
DOH
DPP
DSH
DSMP
Definition
Area Agencies on Aging
Aged, Blind, Physically Disabled
Affordable Care Act
Adult Day Health Care
Aging and Disability Resource Centers
Assisted Living Program
Blended Case Management
Behavioral Health
Behavioral Health Organization
Balancing Incentive Program Initiative
Children’s Single Point of Access
Care at Home
Consumer Assessment of Healthcare Providers and Systems
Certified Nurse Aide
Child and Adolescent Needs and Strength – New York
Clinical Assessment Protocol
Coordinated Assessment System
Community Alternative Systems Agency
Community Based Organization
Directed Personal Assistance Program
Core Data Set
Chronic Disease Self-Management Program
Chief Executive Officer
Conflict Free Case Management
Community First Choice Option
Code of Federal Regulations
Certified Home Health Agency
Case Management
Community Mental Health
Centers for Medicare and Medicaid Services
Certificate of Authority
Continuous Quality Improvement
Council on Quality and Leadership
Core Standard Assessment
or Committee on Special Education
Developmentally Disabled
Developmental Disabilities Profile-2
Developmental Disabilities Regional Office
Developmental Disabilities Services Office
Developmental Disability Individuals Support and Care Coordination
Organization
Department of Health
Diabetes Prevention Program
Disproportionate Share Hospital
Diabetes Self-Management Program
G-2
Acronym
EHR
FIDA
FMAP
HARP
HCBS
HCBW
HCQI
HEAL
HEDIS
HH
HH CMART
HIPPA
HRA
ICF
ICM
ID
I/DD or ID/DD
IID
ILC
IPRO
IRMA
ISP
IT
LDSS
LGU
LHCSA
LSC
LTC
LTCC
LTCCC
LTHHCP
LTSS
MAP
MARS
MCO
MFP
MIS
MLTC
MOU
MRT
MSC
MSW
NCI
NCQA
NHTD
NPRM
Definition
Electronic Health Record
Fully Integrated Dual Advantage
Federal Medical Assistance Percentage (Federal Matching Percentage)
Health and Recovery Plans (New York City)
Home and Community-Based Services
Home and Community Based Waiver
Home Care Quality Indicators
Health Care Efficiency and Affordability Law
Healthcare Effectiveness Data and Information Set
Health Home
Health Home Care Management Assessment Reporting Tool
Health Insurance Portability and Accountability Act
Human Resource Administration (New York City)
Intermediate Care Facilities
Intensive Case Management
Intellectual Disability
Intellectual and/or Developmental Disability
Individuals with Intellectual Disabilities
Independent Living Center
Island Peer Review Organization
Incident Report and Management Application
Individual Service Plan
Information Technology
Local Department of Social Services
Local Governmental Units
Licensed Home Care Services Agency
Life Safety Code
Long Term Care
Long Term Care Council
Long Term Care Coordination Council
Long-Tem Home Health Care Program
Long Term Services and Supports
Medicare Advantage Plan
Management and Administrative Reporting Subsystem
Managed Care Organization
Money Follows the Person
Management Information System
Managed Long-Term Care
Memorandum of Understanding
Medicaid Redesign Team
Medicaid Service Coordinator
Master Social Worker
National Core Indicators
National Committee for Quality Assurance
Nursing Home Transition and Diversion
Notice of Proposed Rule Making
G-3
Acronym
NWD/SEP
NYC
NYS
NYESS
NYSOFA
NYSPHL
OASAS
OCFS
OMH
OPWDD
OQPS
PACE
PC
PCSP
POCA
POM
POMP
QARR
RFA
RFI
RFP
RHCF
RHIO
RIA
RN
RRDC
RTF
SAAM
SCM
SED
SEP
SHIN-NY
SOFA
SOD
SPA
SPOA
SSI
START
TABS
TBI
TRAID
TTY
UAS-NY
URL
Definition
Now Wrong Door/Single Entry Point
New York City
New York State
New York Employment Services System
New York State Office for the Aging
New York State Public Health Law
Office of Alcohol and Substance Abuse Services
Office of Children and Family Services
Office of Mental Health
Office for People with Developmental Disabilities
Office of Quality and Patient Safety
Program of All Inclusive Care for the Elderly
Psychiatric Center
Personal Care Service Program
Plan of Corrective Action
Personal Outcome Measure
Performance Outcome Measurement Project
Quality Assurance Reporting Requirements
Request for Application
Request for Information
Request for Proposal
Residential Health Care Facility
Regional Information Exchange Organization
Restrictive Interventions Application
Registered Nurse
Regional Resource Development Center
Residential Treatment Facility
Semi-Annual Assessment of Members
Supportive Case Management
Serious Emotional Disturbance
Single Entry Point
State Health Information Network for New York
State Office for the Aging
Statement of Deficiency
State Plan Amendment
Single Point of Access
Supplemental Security Income
Systemic, Therapeutic, Assessment, Respite and Treatment model
OPWDD Tracking and Billing System
Traumatic Brain Injury
Technology Related Assistance for Individuals with Disabilities
Text-Telephone device for the hearing impaired
Uniform Assessment System-New York
Uniform Resource Locator
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Appendix H: OPWDD Developmental Disabilities Transformation 11/30/2013
Deliverable
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Administrative Memorandum – 2013-# For DISCUSSION, DRAFT 7,
11/25/2013
To:
From:
Subject:
Program Standards for the Provision of Home and Community-Based Services (HCBS)
and Medicaid Service Coordination (MSC)
Effective Date:
TBD (quality reviews to commence six months after provider training on the issued
ADM, see draft BIP work plan/status report for 11/2013)
PURPOSE:
As part of OPWDD’s commitment to support individuals in the most integrated settings appropriate to
individual needs and preferences, this Memorandum communicates and clarifies OPWDD’s intent to adopt the
quality principles and standards that conform to OPWDD regulations and the rules proposed by the Center for
Medicare and Medicaid Services (CMS) in the Notice of Proposed Rule Making (NPRM), May 2012, regarding
the requirements for settings in which Home and Community Based services (HCBS) funded under the waiver
are provided (Part 441.530 or 441.656). OPWDD intends to promulgate State regulations based upon CMS’s
final rulemaking on this matter. In the meantime, this Administrative Memorandum is designed to promote
and communicate the latest OPWDD guidance and to implement enhanced awareness and quality reviews of
these standards across the developmental disability service system with intent for continuous quality
improvement.
Many of these standards are already included in, or are based on, existing OPWDDregulations at 14 NYCRR
Subpart 635-10 and section 633.4 and previous guidance. The proposed CMS regulations provide further
support for current OPWDD regulations and policy as well as formalizing some of what OPWDD has considered
“best practices”.
The guidance and quality standards outlined in this Administrative Memorandum are considered program
standards. 3
APPLICABILITY:
This Memorandum generally applies to all OPWDD providers delivering HCBS funded waiver services and/or
Service Coordination including MSC and Plan of Care Support Services (PCSS), and OPWDD certified
settings in which HCBS funded services are provided including Individualized Residential Alternatives (IRAs)
3
In accordance with Administrative Memorandum #2010-01, “A “program standard” means a standard that, if violated, can lead to
potential sanctions, such as a plan of corrective action, which do not include fiscal recoveries. Sanctions that can be imposed for
violation of program standards are those specified in Mental Hygiene Law (including plans of corrective actions; non-renewal of
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operating approvals; suspensions and limitations of operating certificates, and fines or other fiscal sanctions as well as restitution).”
This means there are no billing standards intended and included in this Memorandum and as such there is intentionally no shaded
language to identify billing standards.
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and Family Care Homes. HCBS funded services include but are not limited to: Day Habilitation, Residential
Habilitation, Prevocational Services, Community Habilitation, and Supported Employment Services. 4
This Memorandum describes the quality principles and standards that OPWDD deems essential in assessing
whether waiver services and supports provided to each individual are person-centered, community based, and
delivered in the most integrated setting appropriate to each individual’s needs and preferences.
QUALITY PROGRAM STANDARDS:
The following are quality program standards and characteristics for the delivery of HCBS funded services and
Service Coordination. These standards address the person centered planning process; delivery of person
centered HCBS funded supports and services in integrated settings; promoting and supporting informed
choice and rights; and standards applicable to each person’s living situation.
It is expected that these standards are promoted and facilitated by all Service Coordinators, OPWDD certified
facilities/sites, OPWDD funded HCBS providers/programs, and staff delivering HCBS funded services/supports
to individuals in the HCBS waiver.
A. Guidance on the Person Centered Planning Process and Delivery of Person Centered HCBS Waiver
Services in Accordance with These Standards:
Practice guidance on person centered planning and service delivery can be found on OPWDD’s website under
the “Person Centered Planning” link at:
http://www.opwdd.ny.gov/opwdd_services_supports/person_centered_planning.
This practice guidance on person centered planning and person-driven service delivery is the responsibility of
all providers and staff that support the individual not just the author of the person’s plan(s). OPWDD expects
that these principles and practices are embraced by all providers and staff that work with people with
developmental disabilities. Services and supports should be designed to result in greater choice, autonomy
and independence and emphasize the outcomes that matter most to each person.
B. HCBS Waiver Service Provision Is Required in Integrated Settings:
HCB waiver services and supports must be designed to facilitate full access to the greater community including
opportunities to engage in community life; seek employment in competitive settings; engage in meaningful
4
This memorandum does not apply to:
• Delivery of HCBS Respite services;
• Assistive Technology, Adaptive Equipment, and Environmental Modifications funded through the HCBS waiver;
Specifically, except for Respite services, HCBS services funded through the waiver cannot be provided in the following institutional
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settings (HHS NPRM May 2012, pg 26401, 3 column):
• Nursing Facilities;
• Psychiatric Centers;
• Intermediate Care Facilities (ICFs); and
• Hospitals certified for the provision of long-term care services.
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activities; explore meaningful relationships and social roles; reside in the home of choice; and other hallmarks
of community living in accordance with individualized needs and goals, and in the same manner as individuals
without disabilities. Waiver services and supports provided to each individual must be person-centered,
community-based, and delivered in the most integrated setting appropriate to each individual’s needs and
preferences and not be institutional in nature.5
Informed Choice is Facilitated and Rights Are Protected
HCBS service delivery and all settings in which HCBS funded services and supports are provided shall promote
the following:
• Individuals are encouraged to freely choose their daily activities (e.g., when to eat, when to sleep, what
to watch on t.v., etc.).
• Informed choice regarding services and supports and who provides them is facilitated and optimized.
• Individuals freely choose with whom to interact.
• Individuals have the right to access sufficient personal funds for daily activities regardless of the day or
available staff. Arrangements for larger purchases may be made within a reasonable timeframe as
established by regulation 633.15.
• Individuals are treated with dignity and respect.
• Individuals are allowed and supported to have “dignity of risk”.
• Individuals are protected from unnecessary restraint.
• Individuals are informed of and provided with a mechanism to file anonymous complaints.
• Certified settings in which individuals receive services are physically accessible to the person.
Additional Standards in OPWDD Certified Living Spaces:
All OPWDD certified residential settings in which HCBS funded services and supports are provided shall
promote the following in accordance with individual preferences and the strengths, needs, capabilities,
and goals of each person in their plan:
• Food, Meal(s), and Storage of Food Access6
-
-
5
6
Individual have access to food, meal(s), and storage of food (e.g., individuals are allowed to
purchase and store their own snacks or special food and keep food for themselves; kitchens,
refrigerators, and pantries are not locked and if any safety considerations need to be implemented
for a particular individual, the other residents have a means of ready access).
Individuals have input on food options provided (e.g., choices are offered for meals and/or in
menus ).
While it is recognized that mealtimes occur at routine times as is the case in most households, an
individual may choose to eat at a different time or may choose to eat their meals alone if desired.
nd
HHS NPRM May 2012 pg. 26401 2 column
rd
HHS NPRM May 2012, pg. 26401 3 column
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•
Access to Areas of the Home:7
Individuals have access to areas of their home such as kitchens, laundry rooms, cabinets, closets and
other rooms of the house. Such rooms do not have posted hours of operation and are not locked. If
any safety considerations need to be implemented for a particular individual, the other residents have
a means of ready access. Rules may not be posted unless the individuals residing in the home agree to
a schedule that enables everyone equal access.
•
•
•
Visitors and Freedom of Association8:
-
Individual freedom of association, initiative, and autonomy regarding with whom to interact and
when to interact is optimized and not regimented.
-
Individuals may have visitors of their choice at any reasonable time without facility approval and
individuals have the right to privacy with their visitor(s). This also means that individuals have
access to the internet and telephone at any time and may choose to have private telephone
numbers in their rooms and/or private cell phones for use at any time.
-
The facility may require visitors to sign in and/or notify the facility administrator that they are in
the facility or other such policies/procedures to ensure the safety and welfare of residents and staff
as long as such policies and procedures do not unnecessarily restrict visitors for the convenience of
staff and/or regiment freedom of association.
Roommates9:
-
Individuals are provided with opportunities to work with the facility to achieve the closest optimal
roommate situation. Individuals that have issues with their roommates are encouraged and
supported to work things out with their roommates and/or to receive assistance from the facility
staff/facility/provider in coming up with alternatives.
-
The facility has a mechanism to assess roommate satisfaction/dissatisfaction and provides
individuals with a confidential opportunity to discuss issues or concerns regarding their roomates.
The facility also provides education to individuals on self advocacy and supports them in resolving
these issues and/or in moving to another room or residence if the person chooses to do so.
Personal Space and Privacy10:
-
Privacy: Individuals have the ability to lock their rooms for personal privacy and to control access
from unwanted external entry. The locking mechanisms will allow for the entry of support or help
in an emergency.
7
ibit
ibit
9
ibit
10
ibit
8
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Individuals may keep their own key and may lock the door to their private space. Individuals are
allowed to have keys to the house they live in.
-
Personal Items and Decorations: Individuals are encouraged and supported to decorate and keep
personal items in their rooms (decorations must conform to building/fire safety codes and
licensure requirements/rules in certified settings and must not violate the law)
REQUIRED IMPLEMENTATION ACTIONS EXPECTED OF HCBS WAIVER PROVIDERS AND MSC
VENDORS/SERVICE COORDINATORS:
OPWDD expects all HCBS waiver providers and MSC Vendors/Service Coordinators to ensure full commitment
and integration of these quality principles and program standards in all certified sites and be infused in the
planning, monitoring, implementation and delivery of HCBS funded waiver services and supports and Service
Coordination.
1. Governance: The Board of Directors of each organization has appropriate oversight of the
organization’s commitment to these standards and the organization’s continuous quality improvement
plans and strategies involving these principles.
2. All organizational policies and procedures, training materials, and other applicable documents should
be consistent with these standards and ensure that the organization implements policies, procedures,
and practices that clearly define its commitment to the promotion and protection of individual rights.
3. Organizational self-assessment practices that review the degree to which the organization is embracing
and exhibiting these quality standards in day to day operations and strategies for continuous quality
improvement as a result of the self-assessment should be undertaken.
4. Agency training, orientation, and other applicable and ongoing communication, training, and learning
mechanisms should be reflective of these expectations including teaching and encouraging respect for
each individual supported as a unique individual with unique preferences, interests, and goals– teach
listening, learning and responding in ways that honor individuals and increase individual control teach
about individual rights, dignity, and self-determination and how to support individuals to exercise
control and choice in their own lives.
5. Communication with stakeholders including staff and individuals served on these principles and
soliciting feedback from individuals served and their advocates on how to do better through
satisfaction surveys, focus groups, residence meetings, and other applicable forums should be
undertaken.
6. Practices should be undertaken that make clear that the needs and preferences of people supported
determine the types of supports provided. Promote practices that enhance individual decision making
e.g., over schedules, activities, and staff hiring, training, supervising, evaluation, and firing, and in other
areas where individual input and autonomy can be promoted and facilitated.
REVIEW BY THE OPWDD DIVISION OF QUALITY IMPROVEMENT
The Division of Quality Improvement will be revising applicable survey protocols to integrate the above quality
program standards, guidance, characteristics and expectations. Applicable protocols will cover: Person
Centered Planning and service delivery expectations; reviews of certified sites that provide home and
community-based waiver services; and Medicaid Service Coordination. DQI will review these quality program
standards through person centered reviews of individual services and supports and site based service delivery
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as well as organizationally through the systems the provider has implemented to promote and facilitate these
standards.
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Home and Community Based Services (HCBS) Settings – Draft report–
October 24, 2013
Background:
•
The Center for Medicare and Medicaid Services (CMS) Notice of Proposed Rule Making in Federal
Register from May 2012, Volume 77, No. 86, applicable to State Plan Home and Community Based
Services (HCBS) options and Community First Choice outlines quality principles and characteristics
that CMS deems essential for determining whether a setting is “community based”. As stated in the
Federal Register, it is CMS’s intent to align final language pertaining to this topic across sections 1915
(k), 1915 (i), and 1915 (c) Medicaid HCBS Authorities.
•
The provision of supports and services in the most integrated settings possible is a top priority of
Governor Cuomo’s Olmstead implementation efforts and a core component of the New York State
Office for People with Developmental Disabilities’ mission, vision and values.
•
OPWDD recognizes that these HCBS quality principles seek to maximize the opportunities for
individuals to live fully integrated lives in the greater community and will help to ensure that settings
where HCBS services are delivered are not institutional in nature.
•
As a result, OPWD is reviewing its current requirements and guidelines and will seek to ensure full
alignment and integration with these CMS HCBS quality principles. The below sections outline
OPWDD’s preliminary work plan.
HCBS Quality Principles Work Plan Narrative:
In collaboration with a group of stakeholders, OPWDD has drafted a Memorandum that clarifies and enhances
requirements related to delivering HCBS services as outlined in the Federal Register, May 2012. (See draft
attached).
The draft HCBS Administrative Memorandum will be further developed in conjunction with OPWDD’s
stakeholders including individuals served, family members, provider representatives, state staff, representatives
of provider associations, etc. The anticipated timeframe for this further review and editing is Fall/Winter
2013.
After OPWDD issues the Administrative Memorandum and amends all applicable service delivery
documentation, OPWDD will conduct training for individuals, MSCs and service providers to ensure that there
is a complete understanding of the information issued and the responsibilities of all stakeholders.
Winter/Spring 2014.
OPWDD will also begin to develop an independent review process by the Division of Quality Improvement to
assess whether OPWDD settings for individuals in the OPWDD HCBS Comprehensive Waiver meet the HCBS
quality principles and characteristics. This will involve revising existing Division of Quality Improvement
survey protocols, training surveyors, ensuring that performance measures related to HCBS settings can be
collected, compiled, aggregated and analyzed for continuous quality improvement purposes and changes to
DQI’s IT infrastructure. Spring/Summer 2014.
DQI reviews for the enhanced HCBS standards will begin six months after the Administrative Memorandum is
formally issued and training for providers is completed. The anticipated timeframe for these reviews to begin is
fall/winter 2014.
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Once CMS issues its final rules related to HCBS settings, OPWDD will ensure that all guidance and review
protocols align with the final rules.
HCBS Performance Measures related to HCBS Setting Requirements:
•
The OPWDD Division of Quality Improvement will continue to conduct state-wide reviews of all provider
agencies delivering HCBS waiver services and certified sites/facilities where HCBS services are delivered.
While many of the HCBS settings requirements for person-centered planning, choice and control of
resources are already included in OPWDD regulations and DQI’s review protocols, DQI will include
additional performance measures and review components tailored to the HCBS quality principles and
characteristics. Measures will be reported annually to the Department of Health and CMS and analyzed by
DQI to facilitate continuous quality improvement across the service system. The following are specific
measures that are anticipated to be included and/or analyzed for continuous quality improvement strategies
related to these standards:
ASSURANCE
REQUIREMENT/
DOMAIN
Person-Centered
Service Planning
MEASURE
DATA SOURCE
STATUS
The number and percent of National
Core Indicator (NCI) respondents who
reported on the Adult Consumer
Survey that the services and supports
offered meet their needs
The number and percent of
participant’s sampled in which there is
an assessment of the person’s risks,
choices, and need for services.
NCI Survey
Currently being done
DQI Survey and/or
data analysis once
electronic ISP and
assessment systems
are fully implemented.
Similar elements to this
are currently in MSC
review protocol –
The number and percent of HCBS
waiver participants who were
provided information to make an
informed choice on whether to selfdirect their supports and services
during the planning process.
DQI Survey
New measure that will be
implemented January
2014
National Core Indicator Questions on
employment (do you have a job in the
community? Would you like to go
somewhere else or do something else
during the day?
Individual provided with opportunities
to engage in community life (in the
past month: did you go shopping; did
you go on errands and appointments;
did you go out for entertainment, did
you go to restaurant or coffee shop,
did you go on vacation, did you go out
for exercise?
HCBS setting selected by the
individual from among available
alternatives (who chose/picked the
place where you live? Who chose or
picked where you go during the day?)
NCI Survey
Currently being done
NCI Survey
Currently being done
NCI Survey
Currently being done
Questions #: 29, 33, 35
& 36
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ASSURANCE
REQUIREMENT/
DOMAIN
MEASURE
DATA SOURCE
STATUS
Individual is provided with essential
personal right to privacy (do people let
you know before they come into your
home? Do people let you know before
they come into your bedroom? Do
you have enough privacy at home? Do
people read your mail or email
without asking you first? Can you be
alone with friends or visitors at your
home or does someone have to be
with you?)
Individuals share units only at the
individual’s choice (did you choose or
pick the people you live with or did
you choose to live by yourself?)
NCI Survey
Currently being done
NCI Survey
Currently being done
The number and percent of certified
residential settings that meet the
HCBS standards outlined in NPRM
from 2012 as required by OPWDD
requirements.
DQI Survey
New measure. Will be
implemented six months
after provider training on
issued ADM on HCBS
settings
The number and percent of waiver
service providers that meet OPWDD
certification/HCBS standards.
DQI Survey
Current measure. New
HCBS standards
requirements will be
factored into this.
The number and percent of individuals
sampled that received information
about their rights, including the right
to choose where and with whom they
live, and the process to express
concerns/objections in accordance
with requirements.
DQI Survey
New measure. Will be
implemented early 2014.
Qualified Provider
Health and Safety (and
Rights)
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